Orthopedic Coding Alert

Question: When billing for an evaluation and management service (E/M) along with an injection code (20610) should the diagnosis for the injection be a pain code? Do we need to have two different diagnoses? Is this payer-specific?

Mae Chin-Varon
Southern California Orthopedic Institute, Van Nuys, Calif.

Answer: The short answer is this may be payer-specific, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding expert and educator in North Augusta, S.C. For example, some carriers have a policy that a single diagnosis garners one payment for the combination of E/M and procedure, and there are no exceptions. And Callaway-Stradley cautions, to juggle the diagnosise.g., designate knee pain (719.4) for the E/M and effusion (719.06, knee effusion) for the injectionwould not be appropriate and could create audit liability.

The longer answer is that some carriers take a harder line than CPT, which Medicare is aligned with in this case. According to CPT, it should be possible to bill the E/M service.

Callaway-Stradley explains, If you provided a significant and separately identifiable E/M service from the procedure, you should be able to bill the E/M with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), and the diagnosis could be the samefor example, knee effusion. What is a significant level? The key, says Callaway-Stradley, is most carriers expect a new problem or a major exacerbation of an existing problem.

Would follow-up injections ever be eligible for separate billing? Rarely, says Callaway-Stradley. If you have already tried the treatment, you would ask basic questions about its effectiveness before treating again, and those questions are essential to the performance of the procedureand not billed separately.

Even when there is a justification for separate billing, some commercial carriers will delay payment until they have reviewed documentation to verify the modifier -25 criteria are met, says Callaway-Stradley.

But carrier specificity is great and it must be emphasized. For example, in Southern California, Medicare and most local carriers honor the modifier -25. And they do not require two diagnoses. Their only rejection is when the medical-record documentation indicates the patient had been previously scheduled to return for an injection.

Note: See the article Satisfying Medicare for Office Visit and Injection Coding on page 85 of the November 1999 Orthopedic Coding Alert for more discussion of this topic.