March 21, 2007
Dear JCAAI Member:
We recently surveyed JCAAI members regarding reimbursement for an E&M service on the same day as a skin test or on the same day as an injection (95115 – 95117). Well over 80% are paid for an E&M service on the same day as a skin test. Far fewer are paid for an E&M service on the same day as an injection. In particular, the majority of allergists reported that they were not paid for an injection on the same day they billed a minimal office visit (99211).
Under Medicare policy, neither the injections codes nor the skin testing codes have global periods. Codes that have global periods (typically procedure codes) usually cannot be billed with an office visit because the E & M service is considered bundled into the procedure. Codes that do not have global periods do not include any bundling of E & M services; thus, coding policy generally permits them to be billed on the same day as an E & M without the use of modifier-25. However, as our survey results indicate, not all payers are aware of or are following this policy. This may be because, until January 1, 2006, the injection codes were classified as global period codes (which meant that they could not be billed with an E & M service without the use of modifier-25). JCAAI was successful in getting Medicare to change this so that you are allowed to bill an E & M service (including 99211) with allergy injection codes without meeting the requirements for modifier-25. The primary reason for this change was to allow a physician to bill 99211 when dealing with clinical issues surrounding allergy injection administration (e.g., directing a nurse giving injections as to what the nurse should do if a patient was ill, had missed an injection, had a large, local reaction or mild unreported systemic symptoms after their last injection). Medicare agreed that since there was no physician work built into the injection code payment, that it was appropriate to allow payment of a separate E & M service. Although this change technically only applies to Medicare, most commercial payers follow Medicare policy in this area.
Therefore, if commercial payers or Medicare are rejecting claims for E & M services billed on the same day as an injection, JCAAI would like to be notified. In particular, we need to know the identity of the payers and the geographic area. We would also like to know whether you have appealed the denials and the results. Please fax the information to the JCAAI office: (847-934-1820) or email it to info@jcaai.org and include the name of the carrier, the state where they are located, and the EOB’s (be sure to remove the patient identifying information). JCAAI will use this information to make sure payers and Medicare carriers are informed of the 2006 policy change. We will not release your name or other identifying information to any payers, including Medicare, without your specific permission.
In the meantime, if you think you meet the criteria for modifier-25 (e.g. you have provided a separately identifiable service distinct from the injection), you may want to try resubmitting rejected claims with modifier-25 (even though we do not believe this is required). We believe you would probably meet the modifier-25 criteria when billing for higher level office visits which are not related to the injection administration. However, you should make sure you have appropriate documentation. If you are billing 99211 because you were involved in providing clinical advice related to the injection, as described above, do not use Modifier-25 because it is unnecessary and does not apply in this situation. If you have billed both and have been rejected, we believe your next step should be an appeal.
We are aware that billing for an E&M service may trigger a co-pay. In these cases, you may reasonably decide not to bill for the E&M service. JCAAI is developing a plan to try and deal with the high co-pay issue.
We will continue to work diligently to ensure that legitimate billing practices are recognized by both Medicare and third-party payors.
Remember – JCAAI offers allergy specific online learning for socio-economic issues at www.JCAAILearn.org <http://www.JCAAILearn.org> .
Sincerely,
Robert A. Nathan, MD
President of Joint Council of Allergy, Asthma and Immunology