Wiki help with e/m coding

[ahodge90]

I am wanting to make sure that I understand how to properly level an e/m based off of the new e/m guidelines. I keep getting conflicting information on this and was hoping someone could help me make sense of what is right and wrong.

I have a case that I am currently working and was curious if I was on the right track.
The patient is an established patient to our clinic. New to this provider but not to our clinic. (We are a multi-specialty clinic)
The information on this note is pretty limited.
Exam is PF
There was an order for a knee x-ray and the provider reviewed this x-ray saying in the note that there is evidence of patellofemoral arthritis.
Dx is knee OA and the provider did an x-ray and did an steroid shot in the knee.
Provider then told patient to return for follow up in 3 months and told the patient that they may need to have a total knee replacement in the future.

Would I be wrong to say that this would qualify for a 99212-25 with 20610?

the conflicting information i am getting is that since we are billing for the x-ray and the injection, we cannot count for ordering the x-ray but we can count the review and the injection doesn't count towards the MDM. Is this correct?

 

[jkyles]

Hi there, I can't tell if this is a separate E/M visit at all. It looks like a basic work up before the injection so you'd just bill the injection. But if the patient came in for a visit and during the visit the doctor ordered and reviewed the X-ray and then based on the visit and test results decided to perform the injection and there is enough documentation to support a separate E/M visit, you could report the E/M visit without a modifier and add 59 or an X modifier to the injection. See the full descriptors for 25 and 59 in your CPT manual for details on when to use them.

Regarding the review of the X-ray, my understanding of the office guidelines is the review is part of the order and since it was performed and billed in-house you can't count it. Exam isn't used to score the visit. If this is a separate E/M visit it would be based on the complexity of the problem addressed and the risk, which would have to be somewhere in the note.

 

[csperoni]

Seconding @jkyles@decisionhealth.com advice. You cannot count data if you are billing the professional component of a test.
You level based on:
Problem: whether this chronic problem is stable; with exacerbation, progression or side effects of treatment; or with severe exacerbation, progression or side effects of treatment. Could be level 3, 4 or 5.
Data: Likely minimal or none, unless other records were reviewed not indicated here. Level 2
Risk: Did the provider prescribe medication? Order PT? Tell the patient to take ibuprophen? Did the provider actually discuss what is involved in a knee replacement and why it is not recommended at this time? Could be level 2, 3, 4 or 5.
This is all assuming (as mentioned above) that the encounter supports a separate E/M visit.
To me, there is no better outpatient E/M reference than the AMA guide. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
It's 18 months into the implementation, and I STILL refer to it.

 

[ahodge90]

Seconding @jkyles@decisionhealth.com advice. You cannot count data if you are billing the professional component of a test.
You level based on:
Problem: whether this chronic problem is stable; with exacerbation, progression or side effects of treatment; or with severe exacerbation, progression or side effects of treatment. Could be level 3, 4 or 5.
Data: Likely minimal or none, unless other records were reviewed not indicated here. Level 2
Risk: Did the provider prescribe medication? Order PT? Tell the patient to take ibuprophen? Did the provider actually discuss what is involved in a knee replacement and why it is not recommended at this time? Could be level 2, 3, 4 or 5.
This is all assuming (as mentioned above) that the encounter supports a separate E/M visit.
To me, there is no better outpatient E/M reference than the AMA guide. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
It's 18 months into the implementation, and I STILL refer to it.

Thank you so much for this information!

 

[ahodge90]

Hi there, I can't tell if this is a separate E/M visit at all. It looks like a basic work up before the injection so you'd just bill the injection. But if the patient came in for a visit and during the visit the doctor ordered and reviewed the X-ray and then based on the visit and test results decided to perform the injection and there is enough documentation to support a separate E/M visit, you could report the E/M visit without a modifier and add 59 or an X modifier to the injection. See the full descriptors for 25 and 59 in your CPT manual for details on when to use them.

Regarding the review of the X-ray, my understanding of the office guidelines is the review is part of the order and since it was performed and billed in-house you can't count it. Exam isn't used to score the visit. If this is a separate E/M visit it would be based on the complexity of the problem addressed and the risk, which would have to be somewhere in the note.

thank you!