Part B Insider (Multispecialty) Coding Alert

Published on Sun Dec 05, 2004 PDF

Sometimes carriers decide that they're just not going to pay for a medically necessary evaluation and management service on the same day as another procedure, and you have to fight for reimbursement.

That's what orthopedists say has happened recently with joint injections, such as knee joint injections. Carriers have refused to pay for E/M visits on the same day as these injections, even when the doctor performed separately identifiable work.

Example: Say a patient visits the physician, who diagnoses the patient's joint pain as arthritis. Then the physician goes ahead and performs a joint injection. The physician should be able to bill for both the E/M and the injection, says consultant Ryan Price with Aviacode in Salt Lake City, UT.

But Price's clients say the only way they've been able to get the carriers to pay for the separate E/M is by using a different diagnosis. For example, they'll list "knee pain" for the E/M and then the more definitive diagnosis of arthritis for the injection. In fact, coders are supposed to list the definitive diagnosis for both services, Price notes. But some carriers have been rejecting claims where both CPT Codes have the same diagnosis.

"Some companies won't pay for it no matter what," coder Mary Brown with OrthoWest in Omaha, NE says of the separate E/M with joint injections. "I always fight it."

If the patient is scheduled to come in for an injection in advance and there's no separate exam, you shouldn't bill for an E/M visit separately, cautions Brown. But if it's a new problem or the physician hasn't seen the patient in six months, then the physician can legitimately perform an E/M service and bill for it.

"If he comes in and has an E/M and doc says 'try anti-inflammatories for two weeks, and then come back for a joint injection if they don't work,'" then you shouldn't bill for another E/M visit with that previously scheduled injection, says Kim Johnson, director of medical billing services for TPi Billing Solutions in Tulsa, OK.

Strategy: One good rule of thumb is to look at the documentation for the E/M claim and remove all dictation related to the injection, says Brown. If the E/M is at least a level two without any reference to the injection, then you should bill it separately.