Billing an injection and an E/M Takes Work
Modifier 25 is not a free pass to bill separately both services.
By Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC, CSCG, AAPC Fellow
Reporting an evaluation and management (E/M) code in addition to an injection administration code is not a given. Specific requirements must be met before you can append 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 to the E/M code.
an E/M Component
The relative value units assigned to CPT® codes for injections (and all other procedures) include an inherent E/M component. Before any procedure is performed, it’s expected the provider will evaluate the patient to ensure the procedure is the appropriate management for the patient’s condition. For example, when a patient arrives for an injection ordered at a previous visit, the provider will ask questions about the patient’s status to ensure the injection is still the correct course of treatment.
As such, to report a separate E/M service, the E/M component must go beyond that which is normally included in an injection service. In other words, the E/M service must meet the definition of modifier 25.
Meet Injection, E/M, and
Modifier 25 Requirements
Here are some scenarios that can help you swim through this murky water and know when it’s truly appropriate to bill an E/M service in addition to an injection service.
Example 1: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and decides to treat the patient with an injection. The physician administers the injection at this visit. A separate E/M code with modifier 25 is appropriate.
Example 2: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and then makes the decision to treat the patient with an injection. The physician brings the patient back on a different day to administer the injection. At the visit for the injection, the physician documents that the condition is the same and they will proceed with the injection. The injection is administered. A separate E/M code is not appropriate with the injection service.
Example 3: A patient comes in with a worsening condition. The physician evaluates the changes in the status of the condition, looks at options for different treatments, and makes the decision to change the course of treatment and perform an injection, which is completed at the same visit. A separate E/M code with modifier 25 appended is appropriate.
In any situation, when a separate E/M is appropriate, the level of E/M billed depends on the key elements documented within the medical record.
If the documentation is unclear, query the provider by asking what was done differently than what would have been done for any other patient receiving that same injection. You don’t want to “lead” the provider, but you do want to ensure that all the relevant details to support a separate E/M service are documented, if warranted.
Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC, CSCG, AAPC Fellow, has more than 18 years of medical billing and coding and consulting experience. She is the manager of revenue cycle consultants for Visionary Health Group, Community Health Network, Indianapolis, Ind., primarily responsible for managing a team of subject matter experts who perform chart reviews and provider education. Hinkle also teaches billing and coding classes, including the AAPC’s PMCC curriculum, to prepare students for the CPC certification exam. She is a member of the Indianapolis, Ind., local chapter.