I have been getting a lot of email questions about whether or not 96372 can be used for inpatient billing. Here is the exact text of the description of 96372 from the CPT book:
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
The description itself does not specify a location, so I have billed it for many different settings, and I have never had a problem. Here are the notes included with the description
Do not report 96372 for injections given without direct physician or other qualified health care professional supervision. To report, use 99211. Hospitals may report 96372 when the physician or other qualified health care professional is not present.
With cuts to fee schedules across the board, providers are looking for ways to keep their revenue up. I put this list together for one of my new customers and I thought it might be helpful for you guys as well. Please remember, each of these codes needs to be billed with the proper modifiers and all that jazz. Some of my previous posts do have the general rules on how to use the modifier 25 and 59 to make sure you can get paid separately for these additional codes. Ok, here we go.
1. Transitional Care – This set of codes is designed to help decrease the amount of hospital readmissions by encouraging patients and physicians to follow up at the office following a hospital discharge. The insurances pay up to $100.00 per visit more for these services then for regular office visits. You would use CPT codes 99495 and 99496.
2. Smoking cessation counseling – Not every insurance pays for this, but since you are probably doing this anyway, you might as well get paid for it at least some of the time. This code pays between $12 and $17 depending on the insurance and patient’s plan.
Use HCPCS code G0436
Use ICD9 305.1
3. Obesity Counseling – Again, not every insurance pays for this, but most of them will now. They reimburse up to $30.00 in addition to the office visit for this code. A patient’s BMI must be above 30.0 for the obesity counseling to be eligible for payment, and you are probably also doing this already as well.
Use HCPCS code G0447
Use ICD9 codes V85.30 through V85.45
4. Phsyicals – I cannot tell you how many of our doctors have coded their physicals as office visits and lost money for years. Using the proper preventative codes will pay more per visit than regular office visit codes.
Use CPT codes 99381 – 99387 for new patients
Use CPT codes 99391 – 99397 for established patients
Use DX V20.2 for children under 18 and V70.0 for patients over 18
5. Office visits with preventative services – Often people who come in for a physical also then discuss things like adjusting their meds or bringing up new medical issues. Then the doctor will spend a portion of their time addressing things that are not covered under the “risk factor reduction intervention and counseling/anticipatory guidance” that a preventative service covers. In those cases you can code BOTH a preventative code AND an office visit on the same day. We also have a doctor who significantly increased her per visit reimbursement and the overall health of her patients by simply asking her patients if they would like to take care of their upcoming preventative services while they are already in the office for an unrelated medical issue. Physicals, pap smears, and prostate exams happen on a much more regular basis for her patients than in most offices and she increased her monthly revenue by 10-15%. For any questions on how to do this, please see my modifier 25 and 59 post.
6. Injections – To be honest, you will not make any money on the substances themselves. The insurances barely reimburse your costs. Many doctors choose to have things like toradol, rocephin, and kenalog on hand to teat acute pain, infections, and allergic reactions without having to send the patient to an urgent care. If you use the proper modifiers and manage the medical necessity of each line item properly, you can get paid about $30.00 per injection on the administration of the substance. Use the code 96372 and make sure you use the same DX on the J-code as you do on the 96372.
7. Tetanus shots – Many adults only received their tetanus shots in childhood. We have a provider who routinely tells patients who have not received a tetanus shot in 10 years that she would recommend they have a tetanus shot while in the office. Medicare will NOT pay for this unless the patient has been injured (please see my Medicare and Immunizations post). Every other insurance will pay. Our other doctor does it for Medicare patients anyway, but it’s your office is up to you. Insert smiley face here.
Use the CPT code 90714 for TD, 90703 for tetanus toxoid, and 90715 for DTaP
Use ICD9 code V06.5 for TD, V03.7 for tetanus toxoid, and V06.1 for DTaP
PLEASE, PLEASE make sure that you indicate EVERY service you do, even if you think it isn’t reimbursable. Your biller might know some tips and tricks that you aren’t aware of.
As always, if something I suggest isn’t getting paid, email me at email@example.com, or call me at (909) 374-5439. Of course I hope that you will find me so knowledgeable and easy to work with that you will immediately sign up for one of my webinars or call me in for an analysis of your practice. But if that isn’t on your schedule or in your budget, I am still here to help, especially for quick questions like that.
I have an Updated modifier chart for you guys. We have been finding that the insurances are denying the immunization administration (90471) without a 25 modifier on the office visit and a 59 on the 90471. If you were using the old one, please replace it with the updated rules. For a more detailed explanation of how these modifiers work, please see the post from 01/11/13.
And this new chart is fancy and it’s typed and has examples. Hope it helps. I have also had a few inquiries on when to use the modifier 24 and 79, so my next post will be about how to use those effectively. Also, if anyone has a question for us, please do not hesitate to email or comment.
We are training several new employees right now. Glad to be expanding, progressing as expected, blah, blah, blah. But they are having a great deal of trouble with understanding when to use the modifiers 25 and 59. If we are having issues in here, some of you out there might be as well, and I want to make your life easier. First, for you technical types here are the exact descriptions from the CPT book.
Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
Modifier 59 – Distinct Procedural Service:
Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.
Now for some practical application. The modifier 25 goes on the office visit. Here are the situtations in which you need a modifier: 1) If a patient gets a procedure on the same day as an office visit, 2) medication injected same day as an office visit, 3) pap smear done same day as an office visit, 4) physical done same day as an office visit. Don’t worry, we’re about to go through and lay out how we are supposed to use them.
If you need to bill an office visit and a procedure, you would use a modifier 25 on the office visit line. A procedure counts as any CPT code between 10000 and 69999. Plus, you need a different diagnosis on the procedure than you have on the office visit. Here is an example:
A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:
When you put it in with a different dx on the office visit and a 25 modifier the insurance will pay each line item separately.
Paps and physicals work in a similar way. The medical dx go on the office visit and the V-codes go on the preventive service. I could write a whole post on paps (and probably will) but we are going to keep it simple here.
465.9 (ICD10 J06.9) 462 (ICD10 J02.9) 99213 – 25
When you need to bill an office visit and an injection on the same day, you have two options. The cpt 96372 is for an intramuscular injection of a J-code. You can bill the office visit and the substance all day and they will all get paid separately with no modifiers. The injection administration is what the insurances like to include in the office visit. However, you will get paid about $20.00 for each administration billed correctly and that can add up. Say a patient comes in with knee pain and the doctor diagnoses him with osteoarthritis and wants to give him an injection of Toradol. You put the symptom on the office visit with a 25 modifier and the substance and the admin have the condition. Then, you put a 59 modifier on the 96372. So, it would be three line items and it would look like this:
Knee pain 719.46 (ICD10 M25.569) 99213 – 25
Osteoarthritis 715.96 (ICD10 M17.9) J1885
Osteoarthritis 715.96 (ICD10 M17.9) 96372 – 59
I have attached an Updated modifier chart that will tell you when a service needs a modifier. We printed this out and gave it to all the new people and it seemed to clear up most of the confusion.
As always, call or email if you have any specific questions about something that didn’t make it through here on the blog.