Wiki E/M AND INJECTION HELP

[jhastings]

I have a patient who came in for the following:

M54.50
M05.79
F51.01
E03.9
G62.9
M25.511

The doctor gave the patient an injection into the shoulder joint. My question is do I just use the modifier 25?

sorry for the stupid question

 

[jkyles]

I have a patient who came in for the following:

M54.50
M05.79
F51.01
E03.9
G62.9
M25.511

The doctor gave the patient an injection into the shoulder joint. My question is do I just use the modifier 25?

sorry for the stupid question

Hi there, this isn't a stupid question, but it can't be answered based on the diagnosis codes alone. You need look at the rest of the note for that encounter.

For starters, I recommend that anyone who has questions about using a modifier review the complete descriptor, which is in Appendix A of the CPT manual. In this scenario, was the patient new or established? Did the doctor document a separately identifiable E/M visit? These are the sort of things you need to know to determine whether you can report a separate E/M visit.