99213 modifier 25 with 20610

urbach34@yahoo.com

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We have had a debate going on in our office regarding proper coding of 99213 office visit with an injection. The other coder and myself have coded things the same in the past, but we have recently had others start questioning how we are doing things. If a patient comes in with Lt knee pain and stiffness, and ends up being diagnoised with osteoarthritis of the Lt knee, and gets an injection into the knee, are we able to code as follows:

Dx codes: (A)M17.12, (B)M25.562, (C)M25.662

99213-25 (A,B,C)
20610-Lt (A,B,C)
J1040 (Depo Medrol 80mg) (A,B,C)

We are being advised that we cannot tie the same diagnosis to the office visit as we do the injection. We've been told we should only link the pain (M25.562) and stiffness (M25.662) to the office vist, and the osteoarthritis (M17.12) to the injection.

Anyone with feedback on this would be greatly appreciated...
 

cgaston

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I found this out on the web:

"Both the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) have stated that a different diagnosis is not necessary when billing an E&M service and a procedure on the same day.
However, in the same vein, it is inappropriate to bill for an E&M service every time the patient is seen for a planned procedure. Also, keep in mind that despite the AMA and CMS guidance, some third-party payors are not paying for these services unless the procedure and the E&M service are reported with different diagnoses."
 
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Wadsworth, OH
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We have had a debate going on in our office regarding proper coding of 99213 office visit with an injection. The other coder and myself have coded things the same in the past, but we have recently had others start questioning how we are doing things. If a patient comes in with Lt knee pain and stiffness, and ends up being diagnoised with osteoarthritis of the Lt knee, and gets an injection into the knee, are we able to code as follows:

Dx codes: (A)M17.12, (B)M25.562, (C)M25.662

99213-25 (A,B,C)
20610-Lt (A,B,C)
J1040 (Depo Medrol 80mg) (A,B,C)

We are being advised that we cannot tie the same diagnosis to the office visit as we do the injection. We've been told we should only link the pain (M25.562) and stiffness (M25.662) to the office vist, and the osteoarthritis (M17.12) to the injection.

Anyone with feedback on this would be greatly appreciated...

Per ICD guidelines, if a definitive diagnosis is documented, you do not report the signs & symptoms.
 
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Albany
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If the patient is scheduled to come in for the injection, the you can only bill the injection code(s).

If the patient is being seen for a follow up or new patient visit, and the decision is made to do an injection you may append modifier 25 on the E/M code and bill with the injection.

Melissa Harris, CPC
The Albany and Saratoga Centers for Pain Management
 

Pam Brooks

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I would disagree that the E&M code representing the decision to perform a minor procedure can always be billed with a -25 modifier. Although you can use the same diagnosis code, the E&M visit cannot be the decision for the procedure, whether the procedure is scheduled or not--and there has to be documentation that shows significantly more work than that decision. A few years ago, edits were changed to include the decision for a minor procedure to be included in that procedure. From CCI edits (Chapter 1, page 18, revised 1/1/15, effective 1/1/16): https://www.cms.gov/Medicare/Coding...ndex.html?redirect=/nationalcorrectcodinited/

"If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles."


 
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