This page is expanded from a column by David Stern, MD, CPC in the Journal of Urgent Care Medicine, June 2007
Q. When a physician performs an intravenous injection, can we bill for an E/M code as well?
A. Before you give an intravenous injection to a patient, you must evaluate and diagnose the patient. It would seem obvious to expect compensation for the evaluation and management of the patient in this situation. Medicare, however, did not reimburse for a separate E/M code (99201- 99205, 99212-99215) during the same patient visit as an IV drug administration until 2006. The Medicare Claims Processing Manual now reads: “Medicare will pay for medically necessary office/outpatient visits billed on the same day as a drug administration service with modifier -25 when the modifier indicates that a separately identifiable evaluation and management (E/M) service was performed that meets a higher complexity level of care than a service represented by CPT code 99211….For an E/M service provided on the same day, a different diagnosis is not required.”
For example, when a patient presents with a migraine headache and the physician determines that the best treatment is an intravenous injection of prochlorperazine, you should code an E/M code with modifier -25. An E/M code can be properly billed in this situation because the physician had to evaluate the patient in order to conclude that the patient is suffering from a migraine headache, not some other more serious problem (for example: a brain tumor, intracranial hemorrhage, or meningitis).
Note: It is a common misconception that two diagnoses are needed to use modifier -25. According to both Medicare and CPT rules, a separate diagnosis is unnecessary. Although there is only one diagnosis of migraine headache (ICD-9 = 346.00), it is appropriate to bill both for the therapeutic injection and the physician’s evaluation of the patient.
Q. The same patient returns and receives an IV injection – should we use an E/M code?
A. Not always. Here are two situations where you should not bill an E/M code:
· The patient calls the physician, notifying him that the migraine headache has returned. The physician instructs the patient to come into the clinic and receive another prochlorperazine injection from a nurse.
· The patient simply returns to the urgent care center since the headache has returned, and a nurse administers another prochlorperazine injection. The physician makes no personal contact with the patient.
Q. Could we code with 99211, since the nurse is evaluating and managing the patient?
A. What you are asking makes sense, but Medicare does not reimburse for this code (99211) when submitted along with an intravenous injection code. Prior to 2006, many private payors reimbursed for code 99211 on the same day of an injection, but very few private payors still reimburse for this code combination. Even if the nurse in the above two scenarios documents the patient’s vital signs and makes a notation that the patient states that this is a “typical migraine headache,” this is not sufficient for E/M code 99211.
Q. Are there any occasions when we could use an E/M code for a repeat IV injection on a follow-up visit?
A. Since work values are now bundled into drug administration codes, there must be a truly separate evaluation and management for an E/M code to be appropriate. In order to use an E/M code, the physician must personally examine the patient, re-evaluating his condition. The evaluation and management cannot be merely incidental to the procedure. Here are some scenarios for which it would be appropriate to bill an E/M code in addition to the intravenous injection procedure code on a follow-up visit:
- A patient treated for a migraine with a prochlorperazine injection returns to the clinic on the following day, complaining that his headache is much worse than before the first injection. The physician evaluates the patient to see if the patient is suffering from a more serious problem than was previously evident. Finding nothing more than a migraine, the doctor orders another IV injection. Billing an E/M code as well as the injection procedure code would be appropriate.
- A patient returns to a clinic to recheck the condition of her cellulitis. The physician takes an interval history, records vital signs, examines the area of cellulitis, and determines that a repeat antibiotic injection is indicated. An E/M code (with modifier -25) along with the code for the antibiotic injection would be appropriate.