Wiki can we charge office visit with the injection???


Zephyrhills, FL
Best answers
can we charge the office visit with the injection?? please any help appreciated.

Chief Complaints:
1. Bilateral hip.

Appointment type:
Established patient - Established problem Patient returns for the MRI results of both hips. She denies any other complaints .

Unchanged from 12/16/2015.

Medical History: Infection, headaches.

Surgical History: rt shoulder .

Family History:
arthritis, cancer, HTN.

Social History:
alcohol- no
tobacco- no

Medications: None

Allergies: N.K.D.A.


Vitals: Wt 127 lbs, BMI 19.89 Index, Ht 67 in.

Physical Examination:
Examination of the bilateral hips reveals notes of skin abnormality. She has relatively full hip range of motion bilaterally. She does have pain with flexion adduction and internal rotation on the left side. No right-sided pain with this maneuver. No pain with palpation over the trochanteric region bilaterally. Negative straight leg raise bilaterally. Intact sensation bilateral lower extremities. Normal motor sensation pulses and skin examination distally.


1. Pain in right hip - M25.551 (Primary)
2. Pain in left hip - M25.552


1. Pain in right hip
Notes: MRI arthrogram of both hips were reviewed. No evidence of labral tear. No further ossific abnormality noted
I had a long discussion with the patient. I did describe getting her in physical therapy. I did describe doing a one-time steroid injection into the left hip to see how she would respond to this. She was in agreement. We are also going to obtain rheumatologic labs. All questions were answered.

The patient was placed in the supine position. US was placed anteriorly and the femoral head/neck junction was visualized. The skin was prepped. Under sterile technique, using US guidance the needle was placed into the left hip joint. 2cc kenalog and 4cc of marcaine were injected. Patient tolerated procedure well. I did describe infection and flare reaction. All questions were answered.

Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide 80mg

Follow Up: prn
I believe the documentation you pasted in supports billing an E/M in addition to the injection procedure.

If I see my provider has documented & hit items required in the history (for example, chief complaint, elements of HPI...) items required in the multi-system exam (for example, constitutional, musculoskeletal....) & documented items in the decision making (for example, minor problem, sent for lab/xray, recommend PT....) Then I feel confident going to bat for them with the payer...given the level of care billed is supported by that documentation!