Use Caution When Reporting Same-day Injection and E/M

Providers often wish to report an evaluation and management (E/M) service in addition to an injection procedure on the same day. But such reporting is not automatic: Whether this is the best coding option depends on the significance of the E/M service.

For example, the Medicare Physician Fee Scheduled Relative Value File assigns 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) a zero-day global period, which means that the procedure is valued to include an initial assessment and other pre-service work. As such, you would not report an E/M service for a planned injection service where the patient presents without complications or a new problem. To illustrate, the March 2012 CPT Assistant offers the following example:

Evaluation and Management – CEMC

A patient complained of left knee pain. At a previous visit, the physician evaluated the knee, ordered a prescription of a nonsteroidal anti-inflammatory drug and scheduled a follow-up visit in two weeks later for performance of an arthrocentesis if not improved. The patient returned, wherein the physician performed an arthrocentesis and injection of the left knee joint and scheduled a follow-up visit for one month later….

It would not be appropriate to report the E/M service at the two-week follow-up visit because the focus of the visit was related to the performance of an arthrocentesis. Only code 20610 for the arthrocentesis would be reported.

But if the E/M service is significant, and separately identifiable from the typical pre-service work of 20610, you may report the E/M service separately with modifier 25 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 appended.

This is further explained by the following advice, posted on the AAFP website:

 The joint injection codes are assigned a zero-day global period, which means that an evaluation and management (E/M) service should not be billed on the same date. This is because the procedure was valued to include the initial assessment and other pre-service work. However, when the E/M service is significant and separately identifiable from the typical pre-service work of providing the injection, the E/M service may be separately reported with modifier 25 attached. An E/M service should not be billed for a planned injection service where the patient presents with no complication or new problem.

A separate E/M might also be appropriate if the physician provides the injection, and also evaluates the patient for a different and/or exacerbated condition. For example, a patient arrives for a scheduled injection for right shoulder pain, but also has a new complaint of right ankle pain. The physician provides the injection and evaluates the patient for the new complaint. In this case, as long as the E/M service is sufficiently documented, you may report it (with modifier 25 appended) in addition to 20610.

Documentation must substantiate that the E/M service was significant; best practice is to separate the documentation for the injection and the E/M service. If the problem is a pre-existing one, with no significant changes, a separate E/M would be difficult to justify. Only if the E/M service stands on its own may you report it separately with modifier 25.

Your Medicare Administrative Contractor or private payers may provide additional guidance on this subject. For instance, Cigna Government Services and Trailblazer Health have published guidance that says providers are allowed to bill for an appropriate E/M service if they decide to start the series of injections after evaluating the patient during the same visit, “and their documentation supports the level of E/M service billed.”

The same principles explained above apply for all injection services (not just 20610). Don’t accept denials for properly reported claims. If your payer routinely denies an E/M service reported on the same day as an injection procedure, appeal with office notes to show, for instance, that the E/M service was necessary to determine definitive care, or was for a new or exacerbated problem that required additional workup.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 404 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

3 Responses to “Use Caution When Reporting Same-day Injection and E/M”

  1. Tom Wilhoite says:

    It would seem there is an error in the initial description of the example here. The statement, “It would not be appropriate to report the E/M service at the two-week follow-up visit because the focus of the visit was related to the performance of an arthrocentesis.” Possibly should have indicated the one month follow-up for evaluation of the arthrocentesis and not the two week follow-up where the initial arthrocentesis was done.

  2. Mandy Flagg says:

    I believe the example is correct. It states that the patient was in and treated with NSAID’s and scheduled for a follow up in 2 weeks and if no improvement they would do an arthocentesis. At the visit 2 weeks later, there was no improvement with NSAID’s and they performed the procedure. No E&M code would be appropriate at the second visit.

  3. Laura Foster says:

    It is my understanding that a separate E&M can also be charged along with the procedure if the physician would go over and above what would normally be evaluated prior to injection. This would be if PT/X-ray or drug was also prescribed at the time of the procedure. This is over and above what would normally be done prior to the injection evaluation.

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