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Do not append modifier -25 to a drug administration claim for a patient with a prescription

APCs Weekly Monitor, September 23, 2005

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Do not append modifier -25 to a drug administration claim for a patient with a prescription

QUESTION: Is it appropriate to append modifier -25 to an E/M level in conjunction with the administration injections/infusion codes (90780-90781, 90465-90472, 90782-90799, and 96400-96549) when a patient presents as an outpatient with a prescription for his or her injection from their physician, and an RN administers the drug in the outpatient infusion department?

ANSWER: No. CMS has indicated that if you perform "a significant separately identifiable" evaluation and management (E/M) service, you should report the appropriate E/M service code with modifier -25 in addition to codes G0355-G0363, 96405-96406, 96420-96520, 96530-96549.

In your example the provider does not perform a separate and identifiable service. The basic assessment and monitoring of the patient post injection/infusion is inherent in the procedure. Vital signs and basic monitoring do not constitute a separate E/M visit.

Here is an example of when to appropriately append modifier -25: A patient presents for another complaint/service and a physician adminsters a medically necessary injection/infusion as a result. In this scenario, assign both an E/M and the appropriate injection/infusion code. Append modifier -25 to the E/M code.

We recommend you stick with the original OCE edit 21 in which a medical visit (status indicator V) will reject a status indicator S or T procedure performed on the same day without the presence of modifier -25.

Transmittal 129 ("2005 Drug Administration Coding Revisions"), available here: http://www.cms.hhs.gov/manuals/pm_trans/R129OTN.pdf on the CMS Web site, explains this scenario.

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