Wiki E/M visits with injections

[laciehuggins]

If my provider does a 99204 for adrenal insufficiency consult & the provider feels the patient needs hydrocortisone injection, but then also during the exam notices a nodular goiter and does a thyroid u/s, we can bill for both of those with modifier 25, so long as the injection and the u/s are documented in standalone notes?????

 

[vinessachilders]

Take a look at the documentation and imagine removing anything related to the injection and the u/s. If there is enough remaining to support a level four E&M, go ahead and use the modifier to indicate separate services were performed. As long as you use 99204-25 and have the diagnosis for the ultrasound different from that for the E&M, it should support payment for separate services.

If there is not enough remaining, then you should only bill one or the other.