Procedure / visit sameday

[raidaste]

This happens all the time and I've seen different views from alot of people and I'm still second guessing this, so I'm going to try again.

Can I code both the e/m and procedure for this visit:
Pt comes in with knee pain. Doc evaluates, xrays and gives the patient 2 options: 1. steroid med orally or 2. joint injection. Patient decides on joint injection so doc does it.
Is it correct for me to bill 9921x w/ 25 mod and 20610?

[syllingk]

Since the patient wasn't coming in for a pre arranged procedure and the visit is what determined that they needed the procedure and there was more than one management option I woudl say the visit is definitely billable.

[hewitt]

I agree. It sounds a though there was "significant, separately identifiable" work done to evaluate the patient's problem.

[raidaste]

Thanks, I'll stick with my original thinking.