E/M with injection 20610

lsimkins

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I am really confused when it comes to this situation. When is it justifiable to bill an E/M with an injection? I know there is some work that is included in the 20610 but how is that determined? I would appreciate any feedback! Thank you!
 

mitchellde

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If the injection is not a planned activity and the assesment is over above and beyound the neccesity for the injection then you may charge the E&M. For instance to examine the knee and determine the need for an injection is not over and above it is inclusive to the injection, however it is necessary to examine the unaffected knee and for the physician to document this assessment is significant and an E&M can be charged. When the patient returns for a planned injection the assessment is inclusive so there can be no additional E&M, this is injection only. If the patient has a new complaint and still presents for the injection then the assessment is for the new problem so you may charge the E&M and the injection.
 

lsimkins

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Thank you! Your explanation makes it much clearer. The doctors are always marking both and I have had a hard time in the past determining which is correct. Thanks again!!!
 
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