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amccracken1108

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I would like some opinions on this please. Below are snippets of the note, there was the regular hx/social hx/fam hx done. The provider and other coder wants to bill a 99213-25, 20610/J7318 . I do not agree with the 99213. I don't see anything significantly separate from the evaluation of the knee and that is included in the 20610. I have already pointed out what is included in the injection and still was told that there is enough for a 99213. Am i missing something or not interpreting something correctly?

Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code: — Review of patient’s relevant past medical history, — Assessment of the problem area to be treated by surgical or other service, — Formulation and explanation of the clinical diagnosis, — Review and explanation of the procedure to the patient, family, or caregiver, — Discussion of alternative treatments or diagnostic options, — Obtaining informed consent, — Providing postoperative care instructions, — Discussion of any further treatment and follow up after the procedure.

Reason for Appointment
1. LT knee pain
History of Present Illness
Screening:

Patient returns for his left knee. He reports return of his pain over the past month, which is worse in the morning when he gets up. He has undergone steroid injections in the past, his last one was about 3 months ago. He denies any new injuries.
Examination
General Examination:

Examination of the left knee and lower extremity demonstrates intact skin. There may be a small knee effusion. Range motion is from 0 to 130. There is 5/5 extension strength.
Assessments
1.Left knee pain, unspecified chronicity - M25.562 (Primary)
Treatment
1.Left knee pain, unspecified chronicity
Notes: The findings were discussed. Patient has recurrence of his pain and requests an injection. We discussed his options and agreed to trial a gel injection since the steroid injections seem to have a diminishing return. Please see procedure note for more details. He will return as needed.
Procedures
Durolane:
Injection: Intra-articular Injection Durolane.
NDC: 89130-2020-01.
Lot Number: 23440.
Expiration: 01/31/2028.
Notes: The potential risks and benefits of the injection were discussed with the patient. They include, but are not limited to, bleeding, infection and tendinopathy. The patient understands these risks and agrees to undergo the procedure as mentioned. All patient questions were answered, and the patient agrees with the current plan and understands it. The skin was cleaned thoroughly with alcohol and povidone. A pre-filled 3ml (20mg/ml) syringe and 21 gauge, 1.5 inch needle were used for the injection. After negative aspirate, the Durolane was injected using the medial joint line approach with the knee flexed at 90 degrees. The patient tolerated the procedure well.. Post-procedure There were no complications during the procedure. The patient has been instructed in post-procedure care. .
 
One of the ways I think about separately identifiable (and reportable) E/Ms is whether the treating provider was surprised. If the treating provider can reasonably say "I had no idea the patient would need X procedure when I walked in the exam room" then it's a lot easier to accept that the work of an E/M was medically necessary. (Because that's the other thing I think providers lose track of. It isn't just "What did you do?" but also "Did you need to do it?") In this case, they make it clear they were not surprised and there weren't even any new factors they needed to consider before the injection.

Patient returns for his left knee. He reports return of his pain over the past month, which is worse in the morning when he gets up. He has undergone steroid injections in the past, his last one was about 3 months ago. He denies any new injuries.

This is a patient who has had injections for knee pain in the past and is back for another one because their knee pain has returned.
 
Modifier -25 is significant and separately identifiable E&M.
I agree that -25 would not be appropriate based on this documentation. My method is to take the entire note and cross out everything that is part of work of the procedure. That gives you the "separately identifiable" portion. Is what is still there "significant"? If yes, then level based on that leftover portion only. In this case, I don't think there is anything or very minimal separately identifiable.
 
Based on your snip there, does not support a 25 or separate E/M with the injection. Let me guess.... Pt has known OA (?), well-known pt, has been managing with steroid injections, now those aren't working so they have progressed to visco/gel. Will eventually need TKA but trying to put off/hold off as long as possible. Was this also a PA injection clinic? :)
There was nothing else done in the note? No new XR, no changes, no meds, nothing else?

Other good info in other threads here: https://www.aapc.com/discuss/thread...ompliance-issue.203311/?view=date#post-557158
 
amyjph said:
Based on your snip there, does not support a 25 or separate E/M with the injection. Let me guess.... Pt has known OA (?), well-known pt, has been managing with steroid injections, now those aren't working so they have progressed to visco/gel. Will eventually need TKA but trying to put off/hold off as long as possible. Was this also a PA injection clinic? :)
There was nothing else done in the note? No new XR, no changes, no meds, nothing else?

Other good info in other threads here: https://www.aapc.com/discuss/threads/e-m-with-joint-injections-–-orthopaedics-compliance-issue.203311/?view=date#post-557158
Click to expand...
What I put, is the note... just omitted the HX and current meds... there is no DX of OA. The plan, Follow up PRN. Thats it. No meds, no xrays.. Nothing else was done. I tried to prove my point and was shot down. I am not sure how else to approach this, that its not billable.
 
If there's no OA documented, no Durolane...Who is the health plan? If there was better documentation of the decision making about the Durolane that might support it. It was a different decision to do that than another steroid it appears. What needs to be improved is the documentation, decision making and thought process around the Durolane decision. That is not captured here. This is a CDI conversation. Does the patient have any other medical conditions that would be impacted, what was discussed about the change of drug? Etc. Was the gel injection discussed in a prior visit as a standard progression? Did they also claim a level 4 or 3 in all prior visits for this same type documentation?
Ask them both to show you where an E/M was supported and modifier 25 was supported along with the procedure from this note.

Some links are older dates but the concept applies.

Modifier 25 fact sheet

www.novitas-solutions.com www.novitas-solutions.com
I am all for proper use of Modifier 25 and reporting properly documented E/M with procedures. This note is not it.
 
amyjph said:
If there's no OA documented, no Durolane...Who is the health plan? If there was better documentation of the decision making about the Durolane that might support it. It was a different decision to do that than another steroid it appears. What needs to be improved is the documentation, decision making and thought process around the Durolane decision. That is not captured here. This is a CDI conversation. Does the patient have any other medical conditions that would be impacted, what was discussed about the change of drug? Etc. Was the gel injection discussed in a prior visit as a standard progression? Did they also claim a level 4 or 3 in all prior visits for this same type documentation?
Ask them both to show you where an E/M was supported and modifier 25 was supported along with the procedure from this note.

Some links are older dates but the concept applies.

Modifier 25 fact sheet

www.novitas-solutions.com www.novitas-solutions.com
I am all for proper use of Modifier 25 and reporting properly documented E/M with procedures. This note is not it.
Click to expand...
No OA - and the Durolane was denied for med necessity. That made me question the E/M (I am a CPC and CEMC but I do mainly AR follow up right now). i was getting ready to submit a write off for the injection and checked the E/M because they are notorious for billing E/M with everything. I was told that since the pt complained of worsening pain and they decided on durolane instead of steroids the visit is warranted. If I go thru the note and remove the injection related info, there isnt a billable visit left. there are no other conditions related to the knee. They have been coming in for over a year on a need to come in basis when the pain gets bad. What was in the note, is what I showed here. No discussions on anything, no other plans, the pt knew they wanted an injection and the doc prob knew that too since they have been doing this for over a year. There is no follow up documented. Nothing.
 
Other things going on here. I would be having major heartburn if they were giving gels w/o auth, etc. and had to write them off. Are you an external employee just doing billing and A/R outsourced, or internal? This is a bigger problem. Context is helpful. Since this has now turned into the fact that the claim has already gone out and been denied in part. Was the E/M and injection paid and only the J code denied? The patient is also now going to see on their EOB that the J code was denied and depending on if they are savvy or not, probably call and not be happy.
Is this an ortho practice? If it is that is even bigger heartburn! If so, there has got to be an XR somewhere, and other notes where the patient has had other workup for knee pain. Especially if the pt. has been coming in routinely for steroid injections. Seems crazy they would just be like, ok yup here's a gel...
This also makes me wonder why, if the practice has EMR and edits, the edits would not have stopped this claim in the first place for the J code auth. Unless a coder or biller manually released it. The "notorious" for billing E/M with everything also puts them at risk depending on if they are warranted or not.

As for the E/M, as I said above, it may well be the E/M was warranted due to the decision to now switch to a different drug (new plan). However, the documentation is poor. This is a CDI conversation but is also a pre-auth, don't give out gels where OA is not documented and there is no pre-auth conversation. If I were an A/R rep or a staff coder, this would be something I would bring to my supervisor or manager. If I was the manager I would be pulling reports on the gel J codes and auditing those. Among other things.

It doesn't solve your problem though. The E/M is not supported here with this particular note. Again, they may well have "done the work" and the MDM but it is not documented well. " We discussed his options and agreed to trial a gel injection since the steroid injections seem to have a diminishing return." That statement needs more info. I swear this patient has got to have OA somewhere in their chart.
 
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