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Ruth Ann Santiago
January 18, 2008 @ 2:33 PM Reply  |  Email Friend   |  |Print  |  Top

Has anyone had a problem with insurance company's denying payment for the E/M billed on the same day as Vaccines?  Here is an example of how we are billling:  99213-DX, 90471-DX, 90715-DX.  Most insurance companies are paying the 90471 and 90715 and denying payment for the 99213.  

The insurance companies are telling me that if I use the -25 on the 99213 then they will pay.  According to the description for the -25 modifier, this is used only when a distrinct procedure is on the same date of service.  I don't consider vaccines a procedure.  

According to Medicare the -25 modifier should be used when a procedure with a global period is done on the same day.

Can someone out there give me some advice on how to bill an E/M with the vaccines?  This issue is new.  The insurance companies have only started this denial in November 2007.

Any help would be appreciated.  Thank you, Ruth Ann

Julie A
January 18, 2008 @ 5:08 PM Reply  |  Email Friend   |  |Print  |  Top

We use the -25 on 99213 plus 90471.  I don't know if they get paid, but that is our policy.  We also do that for 90772.

February 18, 2008 @ 4:24 PM Reply  |  Email Friend   |  |Print  |  Top

some payors want it that way so I would start , if they said they would pay.

February 19, 2008 @ 11:33 AM Reply  |  Email Friend   |  |Print  |  Top

Our office also uses modifier 25 for all injections & vaccines and they are getting paid!!

Deepak Jadhav
February 20, 2008 @ 2:48 AM Reply  |  Email Friend   |  |Print  |  Top

We bill the E/M code with modifier 25 and bill the admin codes 90471 and 90772(if applicable) and get paid for all the codes.

Cindy Norling
February 26, 2008 @ 5:49 PM Reply  |  Email Friend   |  |Print  |  Top

Our claim check will actually pend it if the E/M comes in with the modifier 25.  We will go ahead and pay it seeing that the modifier 25 was added, knowing many other payers request it to be added.
It was always my understanding that it was never intended when the administration of immunization codes came out for the coder to have to put a modifier 25 on the E/M code.
I believe some denials might be because there also is a preventive medicene visit on the same day as the E/M, plus the administration of the immunization.  The E/M would be denied without the 25 because it is needed to show it was separate from the Prev.Med. visit.
I am sure there are a lot of payers out there that will deny without the modifier 25, but that really is inaccurate.

Linda B
February 26, 2008 @ 7:06 PM Reply  |  Email Friend   |  |Print  |  Top

This has been a standard in our clinic and our area for years.  The modifier 25 is to be added to EM and preventative care codes if you want to be paid for your admin codes.  90471 90472 are separate and identifieable services from the one you are giving for the EM code.  Usually there are different dx codes if using EM code, but not so with the preventative code.  Do whatever your prime payer in your area expects.  We know that there are many exceptions to the rules.  So we need to bill by the standards of the inurance company if we want payment.  So much for billing ALL carriers equally!

February 27, 2008 @ 10:29 AM Reply  |  Email Friend   |  |Print  |  Top

I do peds coding and I do use mod 25 with E/M code & vaccin.and yes we do get paid.

April 25, 2008 @ 2:02 AM Reply  |  Email Friend   |  |Print  |  Top

Yes, when an injection IM OR IV for an E/M visit then you would append modifier 25. For Medicare or Medicaid, if the injection was just an outpatient injection, then you would code just the injection without an E/M code but for all other carriers you can apply a low level code (99211) for a room charge along with modifier 25. At least, this is the standard for an acute care hospital Emergency Room.

May 12, 2008 @ 8:19 PM Reply  |  Email Friend   |  |Print  |  Top

you can never bill 90772 with and e/m per cpt and medicare.  Are you using the same dx for the e/m and inj when using 90471?  If yes use the V codes for the vaccine and administration.  Hope this helps.

July 25, 2008 @ 7:01 PM Reply  |  Email Friend   |  |Print  |  Top

Could you please help answer a question for me:
I was wondering if you could help me with a denial, I am a new biller getting started.
The Dr is giving the patient an injection of a drug that was purchased by the patient.
I am billing for the office visit: 99213-25=($48), the administration code: 90772=($20),
and the drug J9213 (interferon)= $0 amount.
The claim keeps getting rejected because I am putting a zero dollar amount for the drug.
How do I bill this correctly to get paid for the office visit & administration codes?
Thank you

August 26, 2008 @ 12:31 PM Reply  |  Email Friend   |  |Print  |  Top

I have always billed e/m code with modifier 25 then my injection code, and medicare and medicaid pay! All the other insurance companies pay as well. I also add modifier 59 on my injection code, don't know if it is right or not, but they always get paid!

August 26, 2008 @ 12:33 PM Reply  |  Email Friend   |  |Print  |  Top

don't bill for the drug, the patient brought it in.

February 20, 2015 @ 1:06 PM Reply  |  Email Friend   |  |Print  |  Top

we also use modifier 25 with E&M codes and 59 with Injection and get paid

March 4, 2016 @ 12:38 PM Reply  |  Email Friend   |  |Print  |  Top

Good Afternoon,

Are you being paid by BCBS on the modifier 25 with an injection or J codes?

April 25, 2016 @ 10:23 AM Reply  |  Email Friend   |  |Print  |  Top

don't put anything for the drug - can't believe you are putting interferon and then $0!

October 30, 2017 @ 11:57 AM Reply  |  Email Friend   |  |Print  |  Top

Don't code the drug.

February 25, 2008 @ 11:56 AM Reply  |  Email Friend   |  |Print  |  Top

we also use modifiier 25 on the E & M codes.most all payors will pay injections done same day by using the modifier.

March 11, 2008 @ 1:20 PM Reply  |  Email Friend   |  |Print  |  Top

even when they are coming in for their Well Child Check you append a 25 on the visit when giving immunizations??

Lori O'Neil
February 27, 2008 @ 2:36 PM Reply  |  Email Friend   |  |Print  |  Top

Modifier 25 is used to indicate a significantly separate E&M service (not procedure) was performed on the same day as another service or procedure. If your 99213 visit was a significanlty separate service from the injection then you would apply modifier 25 to your E&M CPT code and both should be paid.

I would caution you--do not automatically apply mod 25 to your visit cpt when performed during the same session as another service or procedure. The visit needs to be a significantly separate service, of which there are rules/examples, and the documentation must support that.

Jamie McHalek, BS, CPC
February 27, 2008 @ 4:55 PM Reply  |  Email Friend   |  |Print  |  Top

Modifier -25 is appropriate (significant separately identifiable procedure or service.  Technically the administration of the vaccine is a procedure.

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