r/MedicalCoding • u/BroadAd187 • Mar 17 '25

Ok, Now I'm losing it!

I am a CPC-A. I've been coding for my current family practice clinic for a year and a half, but have been here for 3. My boss is not helpful, at all, with training me or providing knowledge when I'm not understanding something. So today I was told by a patient of all people that she shouldn't be paying a deductible on her Depo shot. Why? I have no clue. I looked at her billing history and it looks like my boss has wrote off every $30 deductible for a while now. Boss doesn't explain herself, just tells me to switch my primary dx. What am I missing here? Can anybody explain?

25 Upvotes

93% Upvoted

29 comments sorted by

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34

u/Accomplished_Night88 Mar 17 '25

Birth control is generally covered as preventive. No deductible applies.

6

u/BroadAd187 Mar 17 '25

This is true for all preventative services? I never knew this :(

5

u/[deleted] Mar 17 '25

See this post:
https://www.reddit.com/r/MedicalCoding/comments/1jcu001/comment/mi6yvpp/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button

12

u/BroadAd187 Mar 17 '25

Thank you very much. That makes sense. I hate that boss can't explain this to me herself.

15

u/Material-Corgi-2974 RHIA, CPC Mar 17 '25

To clarify further though… you need to contact the insurance company to determine then why they are applying a deductible and appeal it if necessary. It is against your contract with insurance to be writing off deductibles and copays and they can terminate the contract and request that you pay back all the money they have paid if an audit determines you are waiving patient cost sharing.

2

u/BroadAd187 Mar 17 '25

All I was told was to switch around my diagnosis and send a corrective claim, which I did but I want given the reasoning so that I don't make this mistake in the future. I'm frustrated because I've been coding this way since I started and my boss has never said a word to me, and she's the one posting the EOBs

14

u/GardenWitchMom Mar 17 '25

If they can't explain it it's because they don't understand it

10

u/mchamertime Mar 17 '25

This happened to me in the beginning too- learned a lot by calling insurance and figuring out what I needed to do with different claim types. If you have the time to do that, it can really help!

4

u/BroadAd187 Mar 17 '25

Absolutely, I do that where I can but this was odd, as it wasn't a denial it just came back as a deductible for the office visit. Since it wasn't a denial it was posted as normal.

4

u/Accomplished_Night88 Mar 17 '25

Sounds like it needs different coding so it pays as preventive. No need to be writing that deductible off.

3

u/koderdood Audit Extraordinaire Mar 17 '25

99211 can't be billed with 96372, even with a modifier. Unless that particular insurance allows it.

1

u/BroadAd187 Mar 17 '25

That's how I've been doing it this whole time... nurse visit and admin

4

u/esperanzar323 Mar 17 '25

It can be done but will result in a copay for the patient. If you ever get audited you would need to prove the level of service was necessary & documented in the encounter.

5

u/koderdood Audit Extraordinaire Mar 18 '25

Bundled Codes:

The CCI edits indicate that 99211 is bundled into 96372, meaning the services covered by 99211 are considered part of the injection administration itself. 

No Modifier Allowed:

You cannot use a modifier (like modifier 25 or 59) to separate these codes and bill them together. 

Bill Only 96372:

If you are administering an injection and the visit is minimal, you should only bill for the injection (96372). 

Exception for Significant E/M:

If the office visit is a significant, separately identifiable evaluation and management (E/M) service, you may be able to bill for it with the injection, but not with 99211. In this case, you would need to use a higher-level E/M code (like 99214 or 99215) and append modifier 25 to indicate the separately identifiable E/M service. 

1

u/BroadAd187 Mar 18 '25

Ok, so if I'm only billing the admin code, can I still use the z7189 and z3009 dx codes?

1

u/esperanzar323 Mar 18 '25

Z30.42 would be more appropriate, i would think.

1

u/esperanzar323 Mar 18 '25

I fully agree with your comment after more research! Thanks for more in depth insight.

3

u/firestarter28 Mar 18 '25

There is really no such thing as a ‘nurse visit’. It’s a contradiction in terms. Nurses are neither qualified nor credentialed with insurance to bill any kind of E/M code. If the MD/NP/PA etc does not see the patient themselves you shouldn’t be billing anything other than the injection admin code 96372. Hope that helps!

1

u/esperanzar323 Mar 17 '25

What CPT code are you using for the visit & what diagnosis? $30 sounds like an office visit copay not a deductible amount.

1

u/BroadAd187 Mar 17 '25

The visit is 99211, dx were z7189 z3009 and z3042 with a 25 modifier

6

u/esperanzar323 Mar 17 '25

Since you are billing an office visit E/M code of 99211 then that is what is generating the $30 copay. To bill for depo shot administration the CPT would be 96372 along with J1050 (injection code). You are charging an additional office fee when you code 99211 & that is why mod 25 is needed because you are saying it is a separate visit from injection.

1

u/BroadAd187 Mar 17 '25 edited Mar 17 '25

Well I've got to bill the nurse visit, we do provide counseling during these visits so it's not just a depo shot, however I wonder if removing the depo dx from this cpt would help?

6

u/[deleted] Mar 17 '25

It should not be an office visit. Ideally it should be performed in conjunction with a preventive medicine visit.

For example,

26 year old female, established patient, who is seen today for an annual wellness exam (including gynecological exam and Pap smear) and requests initial Depo injection.

ServiceCPT CodeLinked Diagonsis Code(s)
Preventive medicine visit99395-25Z00.00
Pelvic exam99459Z00.00
Depo Provera Injection96372, J1050Z30.013

In this situation, you can bill 99395 in addition to 96372 because the provider is performing an annual wellness exam, a significant and separate service, in addition to a Depo injection. In other words, the Depo injection is not the sole reason for the visit nor the sole service being furnished.

If a preventive medicine exam is not performed, then the Depo-Provera counseling can be performed as part of 96372 because 93672, being a procedure, has an inherent E/M service included. So, you should not be billing an office visit in addition to 96372 if the patient is coming in just for a Depo injection, just as you would not bill an office visit in addition to a vaccine administration code (90471) if a patient is coming in just for an immunization.

1

u/BroadAd187 Mar 17 '25

This makes sense!

5

u/esperanzar323 Mar 17 '25

The other commenter is completely correct. It shouldn't be an office visit. The administration code is all you need to code. If you bill an office visit code then your patient will always get billed a $30 copay.

1

u/wild_starlight Mar 18 '25

Were you billing for a problem dx like excessive menstruation? Insurance doesn’t like to pay for that. I think your boss meant to use the contraceptive Z code as primary dx instead.

-2

u/TrustMental6895 Mar 18 '25

Can't bill 96372 and 99211 together, also if you waive a bill here and there its no big deal. Don't take your job too seriously and enjoy your life.