Coding for Basic Injections in the Primary Care Practice

While auditing a primary care practice’s charge slips last week, I realized that the group of physicians and other qualified health care professionals I was working with had no understanding of coding for basic injections. In fact, as I reflected on all the primary care offices I had visited over the past months; improper coding of injections seemed to dominate the list of coding problems. Since the majority of codes are chosen from a list within the electronic medical record, I would recommend changing the wording linked to the CPT/ HCPCS II codes for easier recognition. Many EMR lists show partial wording which can confuse any practitioner. I will focus on the most commonly used injection codes used within a PCP practice. There are many other injection codes incorporated into CPT, but these will not be addressed since they are not commonly used in a primary care office.

Coding for Basic Injections in the Primary Care Practice

ALLERGY SHOTS

Let’s begin with the basic allergy shot(s): 95115 and 95117. These two codes include the professional services necessary when providing allergen immunotherapy so no E/M code would be added to the visit. In other words, the patient enters the doctor’s office and receives his allergy injection(s) and leaves. However, a provider CAN use an E/M service if other medical issues are addressed in addition to the allergy shots. For example, a rash or conjunctivitis would necessitate additional work-up allowing for an E/M code with modifier 25 (significant, separately identifiable E/M service by same provider on same day of a procedure or other service).

The proper way to code for one allergy shot is 95115. For two or more injections you would use 95117 only. Regardless of the number of allergy shots given, you will use only ONE code: 95115 (1 injection) or 95117 (2 or more injections).

Subcutaneous or Intramuscular Injection

CPT code 96372 is used for therapeutic, prophylactic, and diagnostic injections. When using 96372, it is important to specify the substance or drug being injected. For example, a B12 injection would be entered with CPT Code: 96372 (SC/IM) and HCPCS II Code: J3420 (Vitamin B-12 up to 1,000 mcg). For coders or medical billers, be aware that when setting up your HCPCS II medication codes, you must also enter national drug codes (NDC) information in order for claims to be accepted. The NDC is a universal number that identifies a drug and consists of 11 digits in a 5-4-2 format. If the NDC contains less than 11 digits, zeroes must be entered in front of the numbers. For example: 0XXXX-XXXX-XX or XXXXX-0XXX-XX. For more information on NDC visit the US Food and Drug administration at www.fda.gov/Drugs/informationOnDrugs. Vaccines do not require NDC numbers.

Vaccinations

There are numerous ways for a patient to receive a vaccine injection. However, my intention here is to focus on the most commonly used codes which are 90471 and 90472. For whatever reason, providers consistently confuse 96372 with 90471 but 90471 is strictly linked to vaccination administration. The most important fact to remember when listing the actual vaccine with the 90471/90472 administration code is that you must include the vaccine as the product injected.

IF, however, the vaccine is state supplied, you must add modifier SL, which tells payers the vaccine was given to the practice by the state for free. You can change the amount to .00 dollars on the claim but even with a dollar amount, the SL modifier will stop payment on the vaccine. If the PCP injects a vaccine that the office paid for, eliminate the SL modifier so that you may get reimbursed.

Thousands of dollars are lost on vaccines because providers do not include it on their encounter form and coders/billers often assume it was a free vaccine. When coding 90471 this is considered percutaneous, intradermal, subcutaneous, or intramuscular. This is for one injection or a combination vaccine/toxoid. For each additional vaccine administered, list 90472 after the 90471.

*Special note: Medicare uses HCPCS II codes for vaccination injections: Seasonal Influenza Virus Vaccine – Administration Code: G0008 (not 90471) with Diagnosis Code: V04.81. Pneumococcal Vaccine – Administration Code: G0009 (not 90471) with Diagnosis Code: V03.82. Pneumococcal and Seasonal Influenza Virus – Vaccines received during the same visit – Administration Codes: G0008 for the Influenza Virus AND G0009 for the Pneumococcal with Diagnosis Code: V06.6. Lastly, Hepatitis B Vaccine Administration Code: G0010 (not 90471) with diagnosis Code: V05.3. For more information regarding Medicare vaccination administration, visit: www.cms.gov and click on Outreach and Education.

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