Billing E/M with 25 - Injections

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I am trying to clarify appropriate coding for injections that a provider may perform on new patients. I work in a hybrid Urgent Care/Primary Care setting that has a PA specializing in Orthopedics. Often times, a new patient (Urgent Care) will come in with say joint pain and the PA will perform a full evaluation prior to determining treatment, which may or may not include injection.
As an example, he will see a patient for knee pain. He takes a history, examines them, takes xrays. After doing all of this, he determine that they have osteoarthritis of the knee. He will discuss all of the treatment options with them, which can include, activity modification, prescription NSAIDs, joint injection, and surgical referral. Many patients can opt for any of these, and any of them can be viable treatment options.
In this example, he performs a full workup, and then following discussion makes the decision to perform a knee injection CPT code 20610. The injection was not planned at presentation, and also not necessarily a distinct part of the visit, ie we chose to perform the injection today on top of the new patient evaluation.
It seems appropriate that I would code this patient as a 99203 with a 25 modifier and the 20610 CPT code. This is in contrast to if he had been seeing the patient for a few visits, and had previously discussed cortisone with them, and they came in and he would inject them. In that case, I would just code the 20610. I have been getting audit feedback that I should not code the E/M with a 25, that only the 20610 should be coded since the E/M is not a distinct service. I am in the NGS jurisdiction and do not know if this coming into play with the ruling. Can you please weight in with correct coding for this scenario. Thank you!
 

thomas7331

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My personal opinion is that it sounds like you have a good understanding of the guidelines and are coding this correctly. CMS guidance on the use of modifier 25 states that it is supported when the documentation "indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service." In addition, the guidance specifically states that a different diagnosis is "not required for reporting the E/M service on the same date as the procedure or other service" which I interpret to mean that there is no requirement that the provider be evaluating other unrelated conditions - only that the E&M performed is more than what would be associated with just performing the procedure. If your provider, as you describe, is making the initial diagnosis of the osteoarthritis, reviewing x-rays, discussing alternative treatment options, then in my mind this is certainly beyond the usual peri-operative care involved in an injection.

That said, I think that the documentation requirements for modifier 25 are probably one of the greyest of the grey areas in coding, which means that you are probably going to get a different answer depending on who you ask and on how each individual note is documented. Coding involves making a judgment, and different coders and auditors will often make different judgments about the same medical record - such is the nature of the work, and I've never felt that this means that one coder is right and the other is wrong.

If your auditors are giving you this feedback, I would try to have a discussion with them about what specifically they are looking for in the record to support a modifier 25, or what guidance they are using as a reference to come to the conclusion that your coding is incorrect so that you can align your coding with their expectations. If they can't tell you this in clear and understandable terms, then in my opinion they shouldn't be citing this as an error in your coding.
 

erjones147

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While I agree with both of you from an academic standpoint, allow me to at least bring up a "devil's advocate" point....

Remember that the first coding passes for a payor are computer-based edits. I do not know for sure, but it's my guess that your claims (and mine, too) are getting denied because the computer edit does not have the ability to see that a "significant and separate" service is being done. All it sees is one dx and two CPT codes - auto denial for "unbundling." However, if the provider also briefly checked on the patient's HTN, then you could get a 9921x-25, 20610 (with the 9921x code linked to the HTN, and the 20610 code linked to the OA)

Thomas has much more experience in this area than I do, so I look forward to his response
 

trarut

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I am trying to clarify appropriate coding for injections that a provider may perform on new patients. I work in a hybrid Urgent Care/Primary Care setting that has a PA specializing in Orthopedics. Often times, a new patient (Urgent Care) will come in with say joint pain and the PA will perform a full evaluation prior to determining treatment, which may or may not include injection.
As an example, he will see a patient for knee pain. He takes a history, examines them, takes xrays. After doing all of this, he determine that they have osteoarthritis of the knee. He will discuss all of the treatment options with them, which can include, activity modification, prescription NSAIDs, joint injection, and surgical referral. Many patients can opt for any of these, and any of them can be viable treatment options.
In this example, he performs a full workup, and then following discussion makes the decision to perform a knee injection CPT code 20610. The injection was not planned at presentation, and also not necessarily a distinct part of the visit, ie we chose to perform the injection today on top of the new patient evaluation.
It seems appropriate that I would code this patient as a 99203 with a 25 modifier and the 20610 CPT code. This is in contrast to if he had been seeing the patient for a few visits, and had previously discussed cortisone with them, and they came in and he would inject them. In that case, I would just code the 20610. I have been getting audit feedback that I should not code the E/M with a 25, that only the 20610 should be coded since the E/M is not a distinct service. I am in the NGS jurisdiction and do not know if this coming into play with the ruling. Can you please weight in with correct coding for this scenario. Thank you!
I agree with your use of the -25 modifier. New patient, coming in for evaluation...it's not a "given" that they're going to get an injection. Decision to treat with injection was made after evaluation and review of all treatment options available to the patient. Same day decision to treat = 25 modifier.

::snip::
If your auditors are giving you this feedback, I would try to have a discussion with them about what specifically they are looking for in the record to support a modifier 25, or what guidance they are using as a reference to come to the conclusion that your coding is incorrect so that you can align your coding with their expectations. If they can't tell you this in clear and understandable terms, then in my opinion they shouldn't be citing this as an error in your coding.
I also agree with Thomas on this. The auditor needs to provide documentation to back up their feedback. This isn't a time why "because I said so" is applicable.
 
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My personal opinion is that it sounds like you have a good understanding of the guidelines and are coding this correctly. CMS guidance on the use of modifier 25 states that it is supported when the documentation "indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service." In addition, the guidance specifically states that a different diagnosis is "not required for reporting the E/M service on the same date as the procedure or other service" which I interpret to mean that there is no requirement that the provider be evaluating other unrelated conditions - only that the E&M performed is more than what would be associated with just performing the procedure. If your provider, as you describe, is making the initial diagnosis of the osteoarthritis, reviewing x-rays, discussing alternative treatment options, then in my mind this is certainly beyond the usual peri-operative care involved in an injection.

That said, I think that the documentation requirements for modifier 25 are probably one of the greyest of the grey areas in coding, which means that you are probably going to get a different answer depending on who you ask and on how each individual note is documented. Coding involves making a judgment, and different coders and auditors will often make different judgments about the same medical record - such is the nature of the work, and I've never felt that this means that one coder is right and the other is wrong.

If your auditors are giving you this feedback, I would try to have a discussion with them about what specifically they are looking for in the record to support a modifier 25, or what guidance they are using as a reference to come to the conclusion that your coding is incorrect so that you can align your coding with their expectations. If they can't tell you this in clear and understandable terms, then in my opinion they shouldn't be citing this as an error in your coding.
Thank you very much for reviewing my question and responding in such detail.
Tracie
 
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I agree with your use of the -25 modifier. New patient, coming in for evaluation...it's not a "given" that they're going to get an injection. Decision to treat with injection was made after evaluation and review of all treatment options available to the patient. Same day decision to treat = 25 modifier.


I also agree with Thomas on this. The auditor needs to provide documentation to back up their feedback. This isn't a time why "because I said so" is applicable.
Got it. Thank you!
 
Messages
7
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0
While I agree with both of you from an academic standpoint, allow me to at least bring up a "devil's advocate" point....

Remember that the first coding passes for a payor are computer-based edits. I do not know for sure, but it's my guess that your claims (and mine, too) are getting denied because the computer edit does not have the ability to see that a "significant and separate" service is being done. All it sees is one dx and two CPT codes - auto denial for "unbundling." However, if the provider also briefly checked on the patient's HTN, then you could get a 9921x-25, 20610 (with the 9921x code linked to the HTN, and the 20610 code linked to the OA)

Thomas has much more experience in this area than I do, so I look forward to his response
Thank you for your response.
 
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