Wiki E/M with Procedure - Who's right?

[pvrossow]

Procedure: Right HIP ARTHROGRAM/INJECTION

After obtaining informed consent, the patient was prepped and draped in a sterile manner on the fluoroscopy table. 9 cc's of local anesthetic was given. Under fluoroscopic guidance, using an anterolateral approach and a 20 guage needle, the needle tip was placed along the lateral one-third of the femoral head/neck region. Intraarticular placement was confirmed using a 2 ml solution of Isovue mixed with 3ml of normal saline. Then a mix of 2 ml 1% lidocaine, 6 ml of .25 marcaine, 3ccs saline and 0.2 ml of Multihance was injected into the hip joint. The patient tolerated the procedure well. Hemostasis was maintained then a band-aid was affixed.

The right hip was examined following the procedure. She reports unchanged groin pain with FABER and no pain with FADIR. She was able to weight bear and ambulate without difficulty. She will continue to monitor her symptoms over the next 24 hours and report back to her ordering physician.

___________________________________________________________________________

The red statement was coded as:

• 27093 - Injection procedure for hip arthrography; without anesthesia;
• 77002 - Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device);
• A4550 - Surgical trays, and;
• Q9967 - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml

The blue statement was coded as:

• 99211-25 - Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional.

Provider is arguing that 99211-25 is supported. They assert that this is a focused exam of the hip following the procedure, beyond simply asking the patient how they are doing or asking them to rate their pain. This is done for diagnostic value based on the short term therapeutic response.” She continued to explain that, “The concern is that a lot of hip pain can be associated with a lumbar spine issue or extra articulate soft tissue injury, not necessarily intraarticular hip joint pathology. The MRI arthrogram of the hip will show abnormalities regardless of whether they are actually contributing to symptoms or not. If the MRI shows a labral tear but the patient receives no pain relief from the injection, this would lead us to believe the labral tear is not symptomatic and therefore should not be treated surgically. The injection of local anesthetic only affects the joint itself.” She then asserted that she “performs this limited hip exam to help the ordering physician determine how much of the patient’s pain is coming from the joint versus an extraarticular source. This is for diagnostic value and I have been asked by ordering physicians to do this.”

I audited the encounter and made the determination that it was inappropriate to bill and be paid for 99211-25 because the blue statement was not considered a significant, separately identifiable service that is above and beyond the usual pre- and post-operative work of the procedure. I state that in this case, the documentation notes that the post-injection exam is directly related to the problem that precipitated the injection, which would not support a separate E/M. If any complications, exacerbations, or presence of other diseases or injuries were determined during the course of this encounter and required additional services, then the documentation would be expected to reflect that, and the required additional E/M services may then be reported separately. For example, if this post-injection exam led to a new diagnosis, and medical decision making around that diagnosis was performed and documented, then I think a separate E/M service would be warranted. However, that doesn’t appear to be the case here.

Who's right here? Thanks for your help!

 

[thomas7331]

To start with, the code itself is incorrect. A focused E/M service by the physician should be 99212, not 99211.

But to the question as to whether or not the modifier is supported, I agree with you and would not have coded an E/M service, for the reasons you've given and I believe that most auditors would not allow it since the documentation doesn't really make it very clear why this is 'significant and separately identifiable'. However, in the statement you've quoted, the physician does make a good case for why this service should be billed, which might be a sufficient argument to overturn a denial on appeal - it's unfortunate that she did not include a statement to this effect in the documentation itself. As written, the documentation doesn't really give a coder any clue that this kind of thought process is taking place, but to a physician it might be obvious.

I don't think there is a 'right or wrong' in grey areas like this - there are just different opinions. But if this is going to be a frequent or routine thing, my advice to the physician would be to improve the documentation to make it more audit-proof - i.e. to make it more clear to a non-physician that this meets the modifier's definition. Overuse of modifier 25 can make you a target of audit, and auditors are usually coders, not other physicians, so may not understand the rationale for these things unless the documentation is more robust than this.

Hope this helps some!

 

[csperoni]

A third vote for -25 not supported in this case. This seems to simply be an brief exam following the procedure to make sure there were not complications.
I agree that if the physician expects to be paid and is doing additional work other than standard pre/post procedure work, the documentation should reflect this.

 

[Blackhorse]

Joint injections are not arthrograms unless a supporting diagnostic report is documented. The red documentation only report the procedure performed and is missing findings from arthrogram. Therefore 27093 can not be billed.

Regarding E/M, I'm curious what is the diagnosis for the visit?

 

[amyjph]

I agree with all the advice above. Neither one is correct from a coding standpoint. I agree that according to the information/documentation provided, the coding is incorrect. The Isovue was being used to confirm placement. This documentation is a hip joint injection (20610). Hip preservation surgeons/sports docs will have this injection done (usually by physiatry) to confirm whether or not the joint is the source of pain/symptoms. It's usually done to confirm FAI, Labral tear, etc. It is also sometimes done as a treatment option. The provider statement you have above confirms this. Just because they do a FABER or FADIR after the injection it is not enough to code an E/M. It's included in the minor procedure.

"To bill an arthrogram, your documentation should include radiographic hard copies of the arthrogram in multiple views and a separate radiological interpretation and report..." (CPT Assistant, July 2008)."

There is nothing in this documentation that supports an E/M. There is nothing documented that supports modifier 25. The highlighted section in red below is key in showing what is included in minor procedures. The exam post-procedure is included. Like Thomas stated you will open a can of worms and be a 25 modifier audit target if 25 is overused incorrectly without supporting documentation.

Because 27093 and 20610 live in the "surgical" section of the CPT book and are considered minor procedures, I would also cite the NCCI manual CHAPTER 1, D. Evaluation & Management (E&M) Services: If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
And: E. Modifiers and Modifier Indicators, b) Modifier 25: Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

This is a chance to educate the provider and partner with them to improve their documentation or just learn that this is not a case where a 25 and E&M is appropriate.
There are a lot of cases where 25 modifiers are appropriate but this is not one of them.

 

[mcdream]

Hi Amy, You mentioned there are a lot of cases where 25 modifiers are appropriate but this is not one of them. May I ask about a scenario?

New patient presents with knee pain, no known injuries or trauma. Provider evaluates the patient, determines diagnosis "likely osteoarthritis of the knee" and decides to treat with a joint injection (20610) administers the injection at this visit. No unrelated issue(s) were addressed.
The focus of the visit was related to the knee pain, which precipitated the knee injection procedure. The evaluation of the knee problem, determining the diagnosis, and the patient's medical suitability for the procedure is included in the injection procedure therefore, it would NOT be appropriate to bill an E/M with the procedure (20610)?

In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.
Since minor surgical procedures and XXX procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

TIA

 

[amyjph]

Hi Amy, You mentioned there are a lot of cases where 25 modifiers are appropriate but this is not one of them. May I ask about a scenario?

New patient presents with knee pain, no known injuries or trauma. Provider evaluates the patient, determines diagnosis "likely osteoarthritis of the knee" and decides to treat with a joint injection (20610) administers the injection at this visit. No unrelated issue(s) were addressed.
The focus of the visit was related to the knee pain, which precipitated the knee injection procedure. The evaluation of the knee problem, determining the diagnosis, and the patient's medical suitability for the procedure is included in the injection procedure therefore, it would NOT be appropriate to bill an E/M with the procedure (20610)?

In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.
Since minor surgical procedures and XXX procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

TIA

That looks like a copy paste from a MAC or somewhere, I know I've read that before This topic is so debated and contentious. In the new patient scenario I would point back to the NCCI manual Chapter IV, B. Evaluation & Management paragraph 6: "The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program contains many, but not all, possible edits based on these principles."

Every one has to be evaluated on the documentation and on a case by case basis. If reporting a separate E&M the documentation would have to meet both the definition of modifier 25 and the requirements of the E&M level being reported.