Wiki can you code E&M and 20610


West Point, NE
Best answers
Wondering if it is appropriate to code an E&M and 20610
Scenario: CC: Lt shoulder pain. He is a elderly white male who presents with compliants of Lt shoulder pain. He said it really hass been acting up for about the last month. He said it catches when he tries to lift it up. He said he can get it all the way up, but then he has to take his hand to let it down otherwise he has severe sticking type pain in the shoulder. He said he did fall on it years ago and wonders if maybe that was the cause of the problem. He has not taken anything for it.
Lt shoulder: He has excellent range of motion. No significat pain with internal/external rotation. He does have a little bit of pain with the abduction. X-ray of the left shoulder 2-3 views show either calcific tendonities or a bone spur on the underside of the acromion.
A: Lt shoulder pain, likely impingement syndrome.
P. He was given injection of Depo Medrol 8 mg and Maracine 3 cc using sterile technique. He had resolution of the pain. He is to recheck PRN.

Please advise. Thanks.
When the decision is made for the injection/aspiration at the time of the EM then it is ok to bill with a 25 modifier, if the patient is coming in for injection/aspiration we only bill the 20610.
At first, I was reluctant to assign modifier 25, and to go with the procedure alone. Modifier 25 does cause a lot of confusion at times. Based on the particular statement in the CPT Appendix A guidelines, "...The E/M serivce may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service." Sometimes the word "significant" puzzles me, and not sure why. Based on that CPT statement, would cast my vote with the above responders. Hopefully those who disagree will jump in with supporting rationale. Suzanne E. Byrum CPC
One of my physicians likes to bill the E/M and the procedure all the time. We generally will bill the E/M if you can pull out the information related to the injury and still have a seperate visit left. The reasoning behind this is because all procedures have a low level E/M built into them. In this example if nothing else is documented I would say only bill the 20610.
From NCCI Edits:

Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M [FONT=Courier New,Courier New][FONT=Courier New,Courier New]Revision Date (Medicare): 1/1/2012 I-21 [/FONT][/FONT]service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.

In the case you provided, I would not bill an E&M with the -25 modifier. There is nothing that showed the provider went over and above what he would normally assess prior to doing the procedure, and no other conditions were addressed. The 'decision to provide the procedure' is bundled into the code for the minor procedures, which includes all investigation leading up to that decision.

CPT and the NCCI edits often don't when in doubt, I always choose to go with the NCCI edits.
Thanks Pam, and as a result of this thread casting some reputation points your way (smiles). Thanks for providing the rationale as your response reveals the disparity between CPT and the NCCI guidelines/edits. So...based on CPT guidelines EM w/25 would be allowed, correct? And if the original poster submits the claim WITH modifier 25 on the EM code AND the procedure 20610 ..... AND if the claim were denied or one of the lines denied, would there be a basis for an appeal IF the carrier doesnt utilize the NCCI edits? Or as you pointed out in your last sentence...."so when in doubt, I always choose to go with the NCCI edits." ? ---Suzanne E. Byrum CPC