Wiki E/m with injection

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adunlap23

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Hi all,

My office had a Highmark audit on modifier 25. Our docs code their own visits, and I’ve been asked to review. I explained a new patient status doesn’t automatically mean the E/M can be billed separately with an injection. But they’re focused on the fact that a full evaluation was done before deciding on the injection.

Does anyone have any resources that support or disprove that a full evaluation on a new patient makes the E/M separately billable with an injection?

Thanks!
 
Generally, any patient, whether new or established, requires some form of evaluation to manage a problem before treatment. This is particularly true for new patients or established patients presenting with a new or ongoing issue. However, if a procedure or service was "planned," you would typically only code the procedure and not an E/M service.

According to the CPT E/M Guidelines, a provider can bill an E/M service with a procedure or service on the same day, even if they share the same ICD-10 code. The critical factor is that the documentation must clearly support the E/M service.

I understand that this can be a source of frustration, as issues with insurance carriers regarding E/M billing and Modifier 25 seem to be ongoing. It often feels like they attempt to downgrade a provider's work to justify non-payment.

The CPT E/M Guidelines are an essential resource for navigating these situations, and I support your providers' opinion on this matter.

Jennifer

Services Reported Separately​

Any specifically identifiable procedure or service (ie, identified with a specific CPT® code) performed on the date of E/M services may be reported separately.

The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. The performance of diagnostic tests/studies for which specific CPT® codes are available may be reported separately, in addition to the appropriate E/M code. The interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT® code and, if required, with modifier 26 appended.

The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT® code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.
 

November 1, 2017 AAPC​

Modifier 25 is not a free pass to bill separately both services.​

By Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC, CSCG, AAPC Fellow

Meet Injection, E/M, and Modifier 25 Requirements​

Here are some scenarios that can help you swim through this murky water and know when it’s truly appropriate to bill an E/M service in addition to an injection service.
Example 1: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and decides to treat the patient with an injection. The physician administers the injection at this visit. A separate E/M code with modifier 25 is appropriate.
Example 2: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and then makes the decision to treat the patient with an injection. The physician brings the patient back on a different day to administer the injection. At the visit for the injection, the physician documents that the condition is the same and they will proceed with the injection. The injection is administered. A separate E/M code is not appropriate with the injection service.
Example 3: A patient comes in with a worsening condition. The physician evaluates the changes in the status of the condition, looks at options for different treatments, and makes the decision to change the course of treatment and perform an injection, which is completed at the same visit. A separate E/M code with modifier 25 appended is appropriate.
In any situation, when a separate E/M is appropriate, the level of E/M billed depends on the key elements documented within the medical record.
 
Gator said:

November 1, 2017 AAPC​

Modifier 25 is not a free pass to bill separately both services.​

By Ellen Hinkle, CPC, CPC-I, CPMA, CRC, CEMC, CFPC, CIMC, CSCG, AAPC Fellow

Meet Injection, E/M, and Modifier 25 Requirements​

Here are some scenarios that can help you swim through this murky water and know when it’s truly appropriate to bill an E/M service in addition to an injection service.
Example 1: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and decides to treat the patient with an injection. The physician administers the injection at this visit. A separate E/M code with modifier 25 is appropriate.
Example 2: A patient comes in with a new condition. The physician evaluates the patient to determine the diagnosis and then makes the decision to treat the patient with an injection. The physician brings the patient back on a different day to administer the injection. At the visit for the injection, the physician documents that the condition is the same and they will proceed with the injection. The injection is administered. A separate E/M code is not appropriate with the injection service.
Example 3: A patient comes in with a worsening condition. The physician evaluates the changes in the status of the condition, looks at options for different treatments, and makes the decision to change the course of treatment and perform an injection, which is completed at the same visit. A separate E/M code with modifier 25 appended is appropriate.
In any situation, when a separate E/M is appropriate, the level of E/M billed depends on the key elements documented within the medical record.
Click to expand...
Thank you for this information. This seems to align with the way my physicians have been coding their office visits. I wonder, though, if this has changed since E/M coding guidelines were revised in 2021. Do you know if there is any information on this since 2021?
 
This was a recent discussion with good input from Dr. Raizman that might help you. Focus on his responses and resource links and references.

Highmark articles:

This one tells you which policies are about Modifier 25:
Modifier 25 Description: Significant, Separate Same Day Procedure Purpose: To be used when reporting an E&M procedure on the same day as another procedure or service. Policies: RP-009, RP-021, RP-023, RP-025, RP-027, RP-028, RP-032, RP-034, RP-042, RP-058, RP-072

You always have to go back to the documentation. Is the provider documenting everything they did at the visit? If you crossed out the sections of the note that were related to the injection, what is left? Is what is left enough to code a stand alone E/M? Does the documentation support "Significant, separately identifiable"? Sometimes it is more about documentation improvement and education. Generally with a new patient you would expect to see an E/M w/ 25 and the injection. Modifier 25 is under scrutiny as always. You have to do internal audits and look at your provider's documentation. Is there more going on? Are they routinely adding modifier 25 to an E/M when the sole purpose of the visit was for an established patient to return for an injection only? Are all of the notes templated and appear cloned between patients? Is the provider doing a full E/M w/ a brand new patient, and is it documented well? That *should* generally warrant separate billing.
For example, new patient comes in with c/o (B) knee pain, trouble walking, using a cane some days, was sent by PCP. Ortho provider orders/reviews (B) knee X-Rays, full ROS, full history, full exam including extended msk. Discusses options, PT, OTC meds like Tylenol, possibly prescription oral meds, option for (B) knee joint injections w/ cortisone. Pt also has Type II diabetes, risks documented and discussed. Pt and provider discuss and decide on injections same day. BMI high, diet and exercise discussion. Diagnosis is (B) knee OA. This would 100% warrant both if the documentation is good. Now, if this same patient keeps coming back for routine injections while working on weight loss. There is minimal exam or anything else done for the known dx, with no health changes, etc. and they are only coming in for repeat injections, that may not support a separate E/M w/ 25 at the established visits later. Depends.
 
amyjph said:
This was a recent discussion with good input from Dr. Raizman that might help you. Focus on his responses and resource links and references.

Highmark articles:

This one tells you which policies are about Modifier 25:
Modifier 25 Description: Significant, Separate Same Day Procedure Purpose: To be used when reporting an E&M procedure on the same day as another procedure or service. Policies: RP-009, RP-021, RP-023, RP-025, RP-027, RP-028, RP-032, RP-034, RP-042, RP-058, RP-072

You always have to go back to the documentation. Is the provider documenting everything they did at the visit? If you crossed out the sections of the note that were related to the injection, what is left? Is what is left enough to code a stand alone E/M? Does the documentation support "Significant, separately identifiable"? Sometimes it is more about documentation improvement and education. Generally with a new patient you would expect to see an E/M w/ 25 and the injection. Modifier 25 is under scrutiny as always. You have to do internal audits and look at your provider's documentation. Is there more going on? Are they routinely adding modifier 25 to an E/M when the sole purpose of the visit was for an established patient to return for an injection only? Are all of the notes templated and appear cloned between patients? Is the provider doing a full E/M w/ a brand new patient, and is it documented well? That *should* generally warrant separate billing.
For example, new patient comes in with c/o (B) knee pain, trouble walking, using a cane some days, was sent by PCP. Ortho provider orders/reviews (B) knee X-Rays, full ROS, full history, full exam including extended msk. Discusses options, PT, OTC meds like Tylenol, possibly prescription oral meds, option for (B) knee joint injections w/ cortisone. Pt also has Type II diabetes, risks documented and discussed. Pt and provider discuss and decide on injections same day. BMI high, diet and exercise discussion. Diagnosis is (B) knee OA. This would 100% warrant both if the documentation is good. Now, if this same patient keeps coming back for routine injections while working on weight loss. There is minimal exam or anything else done for the known dx, with no health changes, etc. and they are only coming in for repeat injections, that may not support a separate E/M w/ 25 at the established visits later. Depends.
Click to expand...
Thank you for your help.
We outsource some of our coding and have a team specifically assigned to review modifier 25 usage. Any claim with modifier 25 automatically gets sent to them before it’s billed out. I’ve looked over their work and trust their decision-making, which is why the audit results really caught us off guard.
After going through the audit myself, I noticed that a lot of the denials involved new patients or patients with worsening symptoms. Sure, some of our physicians could improve their documentation, but most of them are pretty thorough. Many of them have been through this type of thing before and have worked on ways to improve their documentation over the years.
We’re planning to appeal and are trying to find solid evidence showing that a full evaluation or new/worsening problem meets the “significant and separately identifiable” criteria.
 
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