Orthopedic Coding Alert

Question: Ive been told that if an injection and x-ray are performed during the same visit, an office visit has to be charged. If the x-ray and the injection, however, are for the same complaint and the same diagnosis, will the documentation support the office visit and injection charge?

Utah Subscriber

Answer: If the appointment was made for the injection, and no other evaluation and management (E/M) service other than what is related to the injection was performed, then only the injection and drugs are to be billed. An x-ray is an ancillary service, which may be performed independently of any other service, therefore an E/M service is not billed in addition. However, the ordering of the x-ray must be noted somewhere in the patients chart.

Your billing department probably reasons that since the physician ordered the x-ray because of the patients symptoms or complaints, this is part of the decision-making of the E/M codes, and therefore separate from the injection fee.

You are correct in hesitating to bill an office visit in every instance. If there is enough documentation to demonstrate that there was a significant, separately identifiable E/M service, append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service. Dont use the modifier (or the E/M code) if you dont feel the documentation supports the separate service. The note should also justify the medical necessity of the x-ray.