There seem to be 2 real questions/issues here:
1) Is the E/M significant and separately identifiable?
2) IF yes, can you count the risk of the injection toward your MDM leveling?
It is certainly possible to have a significant and separately identifiable E/M the same day as an injection. Historically, this has been overused/abused/misunderstood. As previously mentioned, for a patient being treated for an existing knee pain (and no other problem) it is unlikely to have a significant and separately identifiable visit. Look at the note. Cross out all the information and work that is part of evaluating the patient prior to an injection. Is the separately identifiable information left SIGNIFICANT? Probably not if the clinician has been treating this problem. If during a previous visit, the clinician determined a knee injection would be the next step if not improved, then definitely not. If during this visit, the problem was determined to have worsened, there was a discussion or possible surgery and risks, additional PT, etc., and then after shared decision making, the patient chose the injection, then yes, that's an E/M with -25.
Here's what the
2021 AMA guideline states about it:
The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.
Regarding issue #2, if there actually is a significant and separately identifiable E/M, can you count the risk of the procedure toward your MDM? While this is not explicitly stated in the
AMA 2021 guide, I interpret the existing advice as you may count the risk. Here's my logic:
1) It is specified if you are performing or interpreting a diagnostic test or study, that is not counted toward MDM. It does NOT state procedure.
2) Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
This is all talking about the risk of the actual treatment/management. The risk doesn't change whether or not you are the clinician performing the procedure.
3) Clearly, you count risk of a surgery the clinician will be performing. No one is questioning whether you count that risk. Even if it were the same day (with -57). To me, the same reasoning would apply here.
Summary:
IF the E/M is billable, then you can count the risk of a procedure being performed by the same clinician.