Wiki 99213 modifier 25 with 20610

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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...
 
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."
 
urbach34@yahoo.com said:
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...
Click to expand...

Per ICD guidelines, if a definitive diagnosis is documented, you do not report the signs & symptoms.
 
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
 
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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urbach34@yahoo.com said:
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...
Click to expand...
One "trick" I use to determine what might be considered separately identifiable. I cross off (mentally) anything that has to do with the injection and consider other factors like the reason for visit.

Starting from the top, if the reason for visit indicates that this was a planned procedure in anyway, there is really no room for modifier -25 unless there is another body part addressed.

Initial visits usually always are eligible for modfiier 25 UNLESS it was scheduled as injection and there is no other work-up. This might be the case for fluoro guided hip injections - one provider in the suite may do them while another doesn't.

Diagnosis coding: the pain and stiffness codes are unnecessary. Look at the diagnostic imaging/other outpatient guidelines section in the ICD-10 book (very front). The wording might be different, but it basically states that once a definitive diagnosis (arthritis) is made, pain and stiffness (being signs and symptoms) should not be reported - they are assumed.

So, now we can mention a couple (may not be all-inclusive) scenarios a modifier 25 should apply:
- new patient visit where this provider is establishing the treatment plan (IE not referred and scheduled for injection only)
- established patient coming in for a new problem to be worked up and proceed with injection same day
- established patient scheduled for injection only, with an additional problem addressed. (you code the progress note according to all the elements not crossed off as already included in the e/m inherent to the injection procedure)

There is a grey area, in my mind, when a patient returns for a three or six month injection. Was it planned? Was there resolution to the prior problem, was it OA or just pain/swelling? These are all factors that would have to be individually considered when a patient returns for a follow-up and has an injection. Like I mentioned, start at the top: was it planned
Lastly, remember that joint injections are 0 day global procedures. 0 day and a 10 day global periods should only be appended with modifier -25. Modifier -57 is only when the global period is going to be 90 days, and the actual full discussion, RBA and decision occurred on the day of or the day before surgery.

I hope that helps. I can pull the references if you like.
 
Worker's comp is an entirely different coverage system; any hospital or practice accepting federal dollars does need to follow NCCI, and most commercial payers follow suit. I get it..... private physician practices are taking the hit, but in order to be compliant, we have to understand why this guidance is in place. The pre- and post-procedure work done for minor procedures already includes an element of evaluation and management. That's why NCCI has made it pretty clear; the additional work must be significant and unrelated to the decision to perform the surgical procedure. Otherwise, you've unbundled.
I respectfully disagree that initial visits would usually always (your words) be eligible for the additional E&M. Per NCCI: 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. "Always" is a tricky word in auditing, as each note must stand on its own. But if there's sufficient work having been done outside the minor procedure, it's up to the provider to illustrate that in their note.
 
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