General Surgery Coding Alert

Question: I am told that we cannot bill for an evaluation and management (E/M) on a patient who walks into the office with tendonitis and requires cortisone injection therapy. What is the best way to code for injections, such as when patients come into the office for B12, tetanus, flu vaccine, etc? These are being administered by the nurse practitioner.

New York Subscriber

Answer: If the patient is only coming in for the injection, then only the injection code (i.e., a HCPCS J-code) should be billed, says Felecia Bernstein, CPC, an independent coding and reimbursement specialist in Monmouth County, N.J. If the patient has another problem such as hypertension that might require a blood pressure check, then you can bill 99211 (office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) with a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Many local Medicare carriers, however, now state that the patient must have a reason (i.e., a symptom) to have his or her vital signs checked. You need to make sure your documentation states that there was a need for a vital signs or blood pressure check.

For the cortisone injection, bill only the injection and J code if the shot was scheduled and the patient had no other issues. If the person had swelling or infection, for example, then an E/M code with modifier -25 attached would be appropriate.