Wiki E/M with Procedure Coding


True Blue
Smithtown, NY
Best answers
I have a quick question. I have a surgeon that does injections (i.e. shoulder injections) and likes to add an e/m visit. I know you can bill an E/M with a 25 modifier with same dx but my question is:

what are the keys to look for in the documentation that allows me to bill the office visit with the injection?

does there have to be a specific documentation that the pt DIDN'T come in knowing that s/he was getting it?

This is where I want to be precise as to what keys need to be in the record. Thanks.

If the patient is scheduled for the injection, then you can't bill an office visit. If the doc exams the patient and decides to perform the injection, then you can bill the office visit. You can also bill the office visit if the physician treats a seperate medical condition. That's the readers digest version.

Thanks...that's what I will specifically look for in the notes. We're a billing service and I have minimal contact with the office and almost zero with the specific dr.

When you're in the office you know by looking at the pt's chart and the day's schedule before-hand.

Sometimes it's like flying blind as to what exactly happened on that d.o.s. with that exact pt.