Wiki E/M & Injection same day

[KoBee]

I have an orthopedic provider who keeps billing and E/M with CPT 20610, most of the time they are prescheduled injections and wants to justify the E/M by stating patient continues or still has pain in chief complaint. There isn't no new problem or any other significant exacerbation.

If patient continues to have pain, is that enough to consider a separate E/M every time the patient comes to get injection?

Would like hear if others run into this situation and I want to make sure this is enough to warrant an E/M. Thank you

 

[nrood]

If the reason for visit is for 20610, I would not bill for the office visit unless a separate issue was reviewed on the same day. Pain is not enough to justify a separate charge unless the pain is in a different location.... ie. knee aspiration and also provider adresses shoulder pain or left knee vs right knee, etc. Otherwise, that visit does not seem medically necessary.