Wiki E/M with a 25 when doing an injection?

[Katie_Ellis]

Hello,

I am fairly new to orthopedic coding and our docs do a lot of injections! I am struggling with when it is okay to bill an office visit with the 25 modifier. The guidelines that I was told to go by was that we always bill a new patient (99202-99204) with the 25 when an injection is performed and with established patients, we only do if there is a separate complaint/issue that is addressed. I have researched this and I have found some information saying that as long as the patient is not making the appointment strictly for the injection, then there are instances where you can bill the OV with the 25. Does anyone know what are some things that would need to be dictated in order to do this? If the patient comes in and the doc goes over the diagnosis and other options before they settle on doing the injection, does this warrant the OV? Thanks in advance.

 

[hopepg]

Billing an E/M code on the same DOS as an injection procedure is warranted IF documentation supports it. Keep that "rule" in mind first before looking at anything else (new patient, established patient, appointment reason...).

If the appointment is made for just the injection AND that is all that is documented as done, then the injection administration & J codes are billed with no E/M.
If the appointment is made for just the injection BUT the doctor documented items (HPI, exam....) to support an E/M code, then the E/M, injection administration & J codes are billed.

Hope this helps.

 

[thomas7331]

There's a good article on this in the June 2015 AAPC Healthcare Business Monthly.

The CMS publication Global Surgery Fact sheet is also helpful:

https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf

Medicare generally does not consider the fact that a patient is new to be sufficient in an of itself to support the modifier 25. The E&M that is done has to be more than the usual pre-operative work and if "the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure." There's a lot of grey area here - I think we all struggle with this. But I think it's pretty clear that just documenting a history and exam before the procedure is not really sufficient in and of itself to support the modifier 25.