Orthopedic Coding Alert

Question: When the doctor sees a new patient, evaluates his condition, and decides to perform a joint injection, can we bill for both the E/M and the injection?

Tennessee Subscriber

Answer: When your documentation supports reporting both, most payers will readily reimburse for both a new patient office visit (99201-99205) and an injection (for instance, 20600-20610). When an established patient receives an injection, reporting both an E/M code (99211-99215) and an injection may or may not be appropriate.

One of the best ways to determine whether an E/M and an injection can be billed is to lift your injection procedure out of the documentation. If your notes from the E/M service indicate a significant and separately identifiable E/M service beyond the pre- and post-service associated with the injection, you can bill both codes. Make sure your E/M notes identify the three key elements of history, physical exam and medical decision-making.

You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J.