EM and injection

caroline

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Would anyone know where I could find in any coding guideline, that an EM visit should not be allowed to bill if the sole purpose of the visit was for synvisc joint injection and no other complaint was noted.

Thank you :)
 

Mary Baierl

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My mentor teacher has always taught me that the definition of modifier -25 being "significant and separately identifiable" is the key. As you would need to use a modifier -25 to separate the EM service from the injection service on that same date, being absolutely sure it is significant in the first place and separately identifiable are the keys.

Does this help?
Mary Baierl, CPC, CCA, CMT
 

caroline

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EM and Injection

Thank you Mary. Other than explaining the mod-25 guideline, I thought there might have been an actual guideline on this. But if nothing else I will explain the modifier -25 once more! :)

Thanks again I really appreciate it!
 

renakirk

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Some good resources on this - The CMS Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.B. CPT Assistant has some good explantory articles, for example, Sept, 1998 - "Appropriate Use of Modifier -25," and May, 2003, "Use of Modifiers -25 and -27."

The rules have been consistent for years. Essentially, almost every pateint will have an E/M service on their first visit. After that, if the doctor says come back next week and we'll give you a repeat Synvisc injection - the pateitn comes back, doctors says hi, how are you - any better/worse, etc? Nothing new? O.K., lets proceed with the injection and administers it - here's what to watch out for (bleeding, swelling, whatever) - patient goes home.
The pateint came for the purpose of having the injection, nothing new, no suprises - the injection is all you charge (and medication, if supplied by an independent physician office).

If, however, patient comes back for the second injection, and mentions that he has a swollen area on the proximal calf on the other leg - the doctor looks at it, diagnoses a spider bite, gives some cream samples, and goes ahead with the injection on the one knee - AND properly documents this- you have an E/M in addition to your injection. The expectation was the patient was coming in for an injection and just a routine - hi, how's it going, nothing new or unexpected - and something unexpected, unplanned was there that needed looking into.

Have a great day!
 
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