Primary Care Coding Alert

Question: During an urgent care visit at our after-hours clinic, the on-call family physician (FP) is called out. After he evaluates the patient, another FP comes in and gives the patient a knee-joint injection. What is the proper coding?

Colorado Subscriber

Answer: You should code the E/M service (99201-99215, Office or other outpatient evaluation and management service for the evaluation and management of a new or established patient ...) and the knee-joint injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g. shoulder, hip, knee joint, subacromial bursa) under the second FP's personal identification number (PIN), provided the office visit can stand alone. If it can, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of another service or procedure) to the office visit to indicate the E/M is significant and separately identifiable from the minor history, evaluation and medical decision-making that the injection inherently includes.
 
Tip: Usually, a prescheduled procedure doesn't support a stand-alone E/M. But when history, evaluation, and medical decision-making leads a physician to determine that the patient requires the procedure, the service is more likely to warrant separate billing.
 
Because the individual in your case required urgent care, the injection probably required a separate service to determine the necessary course of action. Therefore, you should consider billing an E/M in addition to the procedure, provided you have proper documentation.
 
When charging the E/M and the injection, use one claim to report both items. If you submitted separate forms using each physician's PIN, the insurer would probably reject one claim.
 
Why: Most payers will not reimburse a same-date service and procedure with identical diagnoses from multiple same-specialty providers. Even though the FPs list their own names on the claims, they share a group identification number. Therefore, the insurer will not recognize that different physicians performed each portion.
 
Best bet: Make sure the FPs tie together their chart notes. Each one should refer to the work the other physician performed. That way you can link the service and procedure together and treat them as one claim.