Wiki E/M and injections

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klp010102

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I have a provider who said she was told she can not bill an office visit if she bills for an injection unless she uses two different diagnosis. An example would be if a patient came in and was treated for knee pain. If she gives an injection with the code knee pain she thinks that she is not allowed to bill the E/M code. I dont agree.

How do you handle these office visits?
 
This is true. Unless the provider has a different diagnosis that he/she is managing than they can only bill for the injection. It has to be a separate and identifiable diagnosis in order to bill for the visit.
 
When you say injection...are you referring to a joint injection (20610) along with an office visit?

CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure

Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim
 
Rebecca speaks truth. The payer may deny but if you have the documentation to support the 25 then you should appeal. If this was a repeat injection the you may not charge the E&M as the assessment for the need for the injection has already been performed at a previous encounter.
 
What your Dr. may be confused about is when a pt has an appointment for an injection and that is all that is done, then, you can not charge an E&M. This is because the "E&M" portion was done at the visit that created this injection visit. If, however, the pt wants the Dr. to look at a "new" problem either before, during or after the injection, then she can bill an E&M with Modifier 25 appended to the E&M code. I hope this helps!
 
LOL now I'm more confused as ever...I have about half telling me no and another half telling me yes. :eek:
 
I agree that a separately identifiable office visit can be billed with the same diagnosis as an injection. I have a follow-up question - I have been advised to append the -25 modifier to the office visit and the -59 modifier to the injection in this type of scenario. Example - 9921X-25, 96372-59, JXXXX - for therapeutic drug injected. Can anyone provide documentation to confirm or deny this? I am uncomfortable with using both modifiers and feel the -25 is the appropriate modifier.
 
E&M and injection

Ouch - don't go putting a -59 on the injection - there is no need for double modifiers. You would only consider a -59 modifier if there was yet another procedure being performed during the same session...

If the patient comes in and complains of knee pain and the doctor decides on an injection, you would code the E&M with -25 modifier and the injection as is.

If the patient is advised to return in say one week for an injection if the pain has not resolved, then just the injection would be billed.
 
Thanks Rebecca. It really helps to have documentation to show the provider. I really appreciate it.
 
E/M injections

Modifier -59 would be used if the injection is done withing the global period of another procedure performed by the same physician. Then, the E/M would also have to have modifier -24, both modifiers conveying to the insurance payers that these services were unrelated to the procedure with the global period. If, in addition to the E/M being unrelated to the procedure and being performed within the global period of said procedure, it is in addition to an unrelated to a procedure done on the same day, use modifier -25 also.
 
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