Medicine: Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy)
Question: An insurance company has refused to pay for an Evaluation and Management (E/M) Office or Other Outpatient Services code (eg, 99214) and procedure code 90765, Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour, when they are both reported on the same date of service. They state the office visit is inclusive to the procedure. What is the appropriate way to report these services when the two (ie, the E/M visit and the intravenous infusion) are unrelated?
AMA Comment: As stated in the guidelines of the Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy), if a significant separately identifiable E/M service is performed, the appropriate E/M service code should be reported and appended by modifier 25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, in addition to the 90760-90779 code series. The guidelines also state that a different diagnosis is not required for the same day E/M service.
Although this reporting method reflects the intent of the CPT code set, third-party payers may request that these services be reported differently. You may wish to contact your third-party payer for specific reporting guidelines.
CPT Assistant Sept. 06: 14