Wiki E/M with Prolia

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LHelmers

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Can lab tests count as part of the pre- and or post work of an injection / infusion? We are struggling with calcium/creatine that are always ordered prior to Prolia and Zoledronic Acid. Could these labs be considered inclusive of the injection or would you count them separate and be able to bill E/M.
 
Agree, the pre, intra and post service work of the injections does not include labs.
Are you billing for a pro-fee/physician office?
When are the labs being ordered? If the provider saw the patient for an office E/M and ordered the labs at that time, they got credit for the lab orders at that visit.
If you are talking about Prolia, if that is being administered once every six months, when is the provider seeing the patient?
If you are talking about Zoledronic Acid, depending on why and if it is the once a year via IV, the provider would have seen the patient and ordered the labs at the E/M visit, correct?

Can you elaborate more on the scenario?

ACR may have helpful billing/coding info if you need help:

**Not saying to always trust these type guides from the drug companies, or that the info is correct, but may have tips. Always go by CPT, ICD-10, HCPCS, Federal and State guidelines**
 
amyjph said:
Agree, the pre, intra and post service work of the injections does not include labs.
Are you billing for a pro-fee/physician office?
When are the labs being ordered? If the provider saw the patient for an office E/M and ordered the labs at that time, they got credit for the lab orders at that visit.
If you are talking about Prolia, if that is being administered once every six months, when is the provider seeing the patient?
If you are talking about Zoledronic Acid, depending on why and if it is the once a year via IV, the provider would have seen the patient and ordered the labs at the E/M visit, correct?

Can you elaborate more on the scenario?

ACR may have helpful billing/coding info if you need help:

**Not saying to always trust these type guides from the drug companies, or that the info is correct, but may have tips. Always go by CPT, ICD-10, HCPCS, Federal and State guidelines**
Click to expand...
The physician typically only sees the patient at the time of the Prolia and Reclast. We are a specialty clinic, and often our patients are driving from hours away, so we don't have them come in-between infusions and/or injections. The labs are being ordered same day. So, I understand the 2 labs counting toward the E/M if there is another category to meet the criteria, but does the condition (M81.0) count as well to justify the E/M? Because 2 labs alone does not as far as I can tell.
 
If the provider is seeing the patient on the same date for an E/M office visit, and there is enough documentation to code an E/M and mod 25 with the injections, you would count the lab order in the E/M. The condition would count as the number and complexity of problems addressed. Or, the provider can code by time depending on how they documented/want to do it.
In your example, they are coming in for an office visit and to do injections. It doesn't sound like a pre-scheduled injection only visit. The provider is seeing the patient and ordering labs to decide (MDM) whether or not to proceed. And, if the patients are not seen in between you most likely would see an E/M. I would assume they may also be considering other conditions the patient may have, possibly they are on other meds, etc. This would all count towards an E/M not the injection. Two separate things.

Take a stand alone note, code it for an E/M, cross all that out and then consider the injections separately.
 
I am referring to a visit with no other conditions and/or meds. Just the injection or infusion with labs. What I am getting from your comment is that the DX (M81.0) for the injection/infusion would count as the Number and Complexity of Problems Addressed and the 2 labs would count in the Data category, warranting a level 3, or low MDM, correct?
 
LHelmers said:
I am referring to a visit with no other conditions and/or meds. Just the injection or infusion with labs. What I am getting from your comment is that the DX (M81.0) for the injection/infusion would count as the Number and Complexity of Problems Addressed and the 2 labs would count in the Data category, warranting a level 3, or low MDM, correct?
Click to expand...
Possibly, it really is going to depend on the documentation of the visit. If it is 1 stable chronic illness, two labs ordered, and an injection/infusion with no identified pt risk factors.
If the provider just says, patient here for injection, labs checked, proceed, and then the note is really just for the injection or infusion you might not have enough documentation to support an E/M.

Do you have a redacted note example?
 
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