Eli's Rehab Report

This is the time of year when PM&R practices begin seeing many more patients with medial epicondylitis (726.31), rotator cuff tendinitis (726.10), plantar fasciitis (728.71) and low back strain (846.9) and that means golf season has arrived again. Many of these golfing-related conditions create tricky coding scenarios because the patient is often treated for more than one symptom at a time, causing the coder to submit claims for E/M visits, cortisone injections and therapy all at the same time. Knowing the ins and outs of coding for these treatments can help coders avoid common pitfalls when submitting claims for commonly treated golf injuries.

"The vast majority of golf injuries that I see are repetitive strain, overuse injuries due to the nature of the sport," says Gregory Mulford, MD, FAAPMR, FAAEM, chairman of the department of rehabilitation medicine at Morristown Memorial Hospital in New Jersey. "In my practice, far less than 5 percent of golf-related injuries require surgery," so most of these injuries can be handled in the office or with the help of a physical therapist.

Physiatrists cannot determine the extent of a patient's injury without a thorough evaluation (99211-99215 for an established patient). If the injury is not very serious, the physician usually gives the patient tips regarding how long to rest and what types of anti-inflammatory medications he or she can use to ease the pain. In addition, the physician may provide information concerning how to avoid future problems by stretching and moving more effectively to remain injury-free. But are exercise tips and demonstrations of strengthening and stretching movements included in the physiatrist's E/M code, or are they separate, counting as therapeutic exercise (97110, Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility)?

"This is a mistake sometimes made by coders who are new to PM&R they see the therapeutic exercise code listed in the PM&R section, and they assign it whenever the physiatrist works on strengthening exercises with the patient," says Dennis Marks, owner of Rivers Coding and Billing, a reimbursement firm in Tallahassee, Fla. "This is not what CPT 97110 was intended for, and you can't ever bill it this way."

Because 97110 should be billed as part of a patient's overall treatment plan, and a code does not exist for a patient whose injury is being evaluated for the first time, this code should not be billed in this situation. Instead, include the physiatrist's review of exercising as part of the E/M code that best fits the visit.

Medial epicondylitis and rotator cuff tendinitis often benefit from cortisone injections to reduce inflammation and pain. Because cortisone injections are coded using 20550*-20551 or 20600*-20610* (depending on the location of the injection), the "starred procedure" rules apply, which may prevent the practice from billing an E/M visit with the injection.

This is because "starred procedures" are surgical procedures, and insurers are allowed to determine what is included in the "global" package billed with the starred code. Most payers bundle the office visit into the injection as part of that global package, assuming that all services done before and after the injection should be included in that code. Each starred procedure is paid differently by Medicare carriers and private insurers, so before billing for cortisone injections, ask the patient's insurer exactly what services are included.

"When a patient initially presents with an injury and the doctor gives him or her the cortisone injection on that first visit, we bill for both the injection and the E/M visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service)," says Dawn O'Keefe, who handles the billing at Seacoast Area Physiatry, a four-physiatrist practice in Portsmouth, N.H. "After that first visit, we still bill for the E/M, but generally it doesn't get paid. Medicare just reimburses for the injection and denies the visit."

The rationale for this is that the first visit requires a comprehensive and detailed examination of the patient's new injury to determine how it would best be treated, and therefore, the injection can be billed with the E/M code (as long as modifier -25 is appended).

You should remember to specify the site injected by using the -LT (Left side) or -RT (Right side) modifiers with the injection code. Or, if bilateral injections are performed, append modifier -50 (Bilateral procedure) to the injection code. In addition, the "J" code indicating the medication injected should be included on the claim. O'Keefe says that her practice most commonly bills J3301 (Injection, triamcinolone acetonide, per 10 mg) as the drug code, although other commonly billed codes include J1030 (Injection, methylprednisolone acetate, 40 mg) and J0702 (Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg).

For example, a patient presents with pain in both shoulders after a weekend golfing trip, and it is a new injury that the physiatrist has never seen before. The patient states that he felt pain in his shoulders halfway through the weekend but continued to golf anyway, with increased pain upon every swing. The physician performs a detailed examination and decides that the overuse, particularly that which occurred after the patient began feeling the pain, resulted in rotator cuff tendinitis. The physiatrist recommends cortisone injections in both shoulders, which he then performs using triamcinolone acetonide. The visit would be coded as follows: