Health Information Management

Q&A: Reporting modifiers with infusions in the ED

APCs Insider, July 24, 2015

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Q: I have been told by our billers that infusion codes reported in the ED along with an E/M code that has modifier -25 (significant, separately identifiable evaluation and management service on the same day of the procedure or other service) require another modifier. I thought that -25 is the only modifier that should be submitted, unless the provider started a second infusion at a second site on the body. This is the first time I’ve been told the infusion coder need a modifier if the E/M has modifier -25 appended.  All of my educational articles tell me that the two can be reported together. Have I missed an update somewhere along the way?
A: Modifier -25 provides information regarding the E/M level and whether it should be considered for separate payment. Because drug infusion services are assigned to status indicator S (significant procedure), an edit is triggered when reported with an E/M level. Modifier -25 serves to further define the relationship between the E/M (ED visit level) and the infusion(s) provided.
As you noted, an edit triggers when you report more than one initial infusion service, as there should only be one unless it is medically necessary for two sites to be used. Other services on the claim may be triggering the need for an additional modifier for the infusion services. For example, if a CT scan with contrast is performed during the ED visit, the edits want to know that the infusion service was not related to the administration of the contrast and the CT scan. If CPT® code 96372 (intramuscular/subcutaneous injection) is reported with the infusion codes, an edit will trigger. This is to ensure that the subcutaneous injection is not being reported for the administration of the local anesthetic that is sometimes used when an IV is started.
Take a look at the services being reported on the claim other than the ED visit level and the infusion service, as there is likely another component in play. If the only services on the claim are the ED visit level and the infusion service, then it is important to see what the edit actually states and where it is originating. Sometimes internal edits or edits in a claims scrubber are created at a particular point in time, and don't get reviewed/changed/eliminated when the guidelines/regulations have changed and the edit is no longer needed.
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Fort Lauderdale, Florida, answered this question.


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