20611 with level 4 E/M?!?!?


San Francisco
Best answers
Hi All,
I really need some help with this one. :confused:I have been in the medical field for 10+ years but am newly certified in coding, so I would like to come at this problem with as much data and references as I can to support my perspective.

Our Sports Med guy keeps billing 20610/20611 cortisone injections along with pretty high E/M services.... I understand that can be ok when it is a "significant and separate" service and -25 is used ... however he is trying to bill for 99214 on one date and 99213 for another date (only 2 weeks apart) and I don't think it is appropriate. This isn't a case of a separate diagnosis or concern being addressed along with the knee injection, the whole visit was about the right knee and suspected plica, but the doctor feels that because he spent so long with the patient answering her many questions that he is justified to bill 99214. I disagree and think that he could MAYBE justify a lower level E/M with the right documentation, but given the diagnosis and scenario 99214 is really pushing it. When I questioned it he said level 4 was justified due to time spent with patient and told me to take out the -25 modifier? Ummmm what?!?!?

So he is obviously in need of some training/education on the subject. Any good articles, references, citations, anything I can present him with?
Much appreciated
Elizabeth J. Simonsen, CPC
Take out the 25 modifier and he definitely will not get paid for the E/M! Lol!

If he is bringing the patient back each visit for the injections, than no - he cannot bill any E/M visit. The first visit where it is established that he will be doing the injections and if an injection is done that day, then he could bill an E/M with the 25 modifier. Otherwise all further visits where the patient is scheduled to have the injections the E/M services would be included (That includes the exam and any discussions and it would be unbundling to bill and E/M with the modifier.

If he feels that he is spending so much time with the patient answering questions, what documentation does he have to support his claim? Even if he could bill an E/M based on time he would need to document at least a brief history, exam and include a summary of what was discussed with the patient. He would also need to show in his documentation that more than 50% of the total time of the visit - with the time listed - was spent in counseling and coordination of the patient's care.

I do not have anything specific to give you at hand at this moment, but there is a lot of information out there on this subject! Do a Google search on the CPT codes, billing for injections, 25 modifier use, etc. and I am sure you will find enough information to support your side!

If not - maybe someone else may have a website handy for you to review!

Hope this helps...Good Luck! I know how stubborn an Ortho can be - I code for one! :)