Can 99214 and 96372 Be Billed Together?
Master compliant billing when providing distinct patient care and procedural services on the same visit. Understand the essential guidelines for accurate claims.
Medical billing for healthcare services can be complex, especially when an evaluation occurs alongside a procedure. Providers must navigate specific guidelines for compliance and accurate reimbursement. This article clarifies considerations for reporting patient assessments and injection procedures together.
Understanding CPT Codes 99214 and 96372
Current Procedural Terminology (CPT) code 99214 represents an Evaluation and Management (E/M) service for an established patient. This service involves a detailed history, examination, and medical decision-making of moderate complexity. It is used when a provider assesses and manages a patient’s health concerns, requiring significant cognitive effort.
CPT code 96372 describes a therapeutic, prophylactic, or diagnostic injection administered intramuscularly or subcutaneously. This code covers the direct administration of the injection, including substance preparation. It is a procedural code, reflecting the physical act of giving the shot. These codes describe distinct services: one for patient assessment and management, and the other for a medical procedure.
Core Principles for Concurrent Billing
When an Evaluation and Management (E/M) service is provided on the same day as a procedure, fundamental principles guide billing. Services must meet medical necessity, meaning they are reasonable and required for diagnosis or treatment.
The E/M service must be “separate and distinct” from the procedure. This means the assessment and management should go beyond the routine pre-service or post-service work inherent to the procedure. Billing separately for components already included within a larger service is considered unbundling, which is impermissible.
Key Requirements for Billing Both Codes
It is permissible to bill CPT code 99214 and 96372 together when specific conditions are met. The Evaluation and Management (E/M) service (99214) must be a significant and separately identifiable service from the injection procedure (96372). This means the E/M work must extend beyond the usual pre-service or post-service activities associated with administering the injection.
The E/M service reason should be distinct from the injection reason, or the E/M must address a new problem or a significant worsening of an existing condition. For instance, if a patient presents with new chest pain requiring a detailed assessment, and during that visit, an injection for their chronic allergy symptoms is also administered, both services may be billable. The E/M service led to the decision for the injection for a new acute problem that required significant assessment.
To indicate the E/M service was separate and distinct, Modifier 25 must be appended to CPT code 99214. This modifier is defined as “Significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service.” Without Modifier 25, payers often bundle the E/M into the injection, resulting in no separate payment for the E/M.
Concurrent billing is not appropriate if the E/M service is solely for ordering or administering the injection, such as a brief check of vital signs before an allergy shot. If the E/M service is minimal and inherent to the injection, like confirming the correct injection site, it should not be billed separately. The E/M must involve substantial additional work beyond what is expected for the injection alone.
Supporting Documentation
Thorough documentation is essential when billing CPT codes 99214 and 96372 together. The medical record must clearly demonstrate the Evaluation and Management (E/M) service was separate and distinct from the injection procedure. This involves detailing the chief complaint, history of present illness, relevant past medical history, physical examination findings, and the medical decision-making process for the E/M portion.
Documentation should establish medical necessity for both the E/M service and the injection. For the injection, specific details such as the drug administered, dosage, administration site, and route must be recorded, along with the reason for its administration. It is important to show how the E/M service either led to the decision for the injection due to a new or worsening problem, or that the E/M addressed entirely separate issues from the injection. If time was used for E/M code selection, the total time spent and activities performed must be clearly documented.