Do You Need an E/M Code for an Injection Procedure?
Question: I have a report for an encounter where an established patient presented for a 10 mg triamcinolone acetonide injection in their left shoulder. Do I assign the evaluation and management (E/M) code along with the injection code, and the supply code? Missouri Subscriber Answer: If the patient presented only for the injection, then you’d assign the injection and supply codes. For example, you’d assign 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) to report the injection procedure and use J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) for the supply. You cannot lump the injection procedure into an E/M code. The payer is also unlikely to reimburse the practice for the supply code without the injection code. “CPT® has established, as has the Centers for Medicare & Medicaid Services [CMS], what E/M work is associated with the injection itself. It includes the decision to move forward with the injection, the discussion of risks/benefits, and the discussion of post-procedure care,” explains Noah Raizman, MD, MFA, CPC, at the Centers for Advanced Orthopaedics in Washington, D.C. The work of the injection procedure does not include the evaluation of the patient, consideration of alternative diagnoses, weighing alternative treatments, etc. If the provider is doing that additional work and documenting it, then that is a separate and identifiable E/M service according to CPT® guidelines. In that case, you’ll report the E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) appended 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). Mike Shaughnessy, BA, CPC, Production Editor, AAPC
