Wiki Help with ov and procedure on the same day

[jnieto625]

I have a patient that was seen for knee pain in July by our pcp. Dr. assessed and decided to inject the knee and patient was told to f/u prn. We billed ov and procedure.
Patient came back in December and saw our PA stating knee pain was back for the past month. The PA injected the knee and ordered an x-ray. Would I could an office visit with the procedure again? I would think that because this patient was already assessed for knee pain in the past, I should only code the injection but I am not sure because this time they decided to order an x-ray.

 

[june616]

Was the knee inj. in December previously scheduled as a follow-up of the first injection (like a series of injections)? If the patient made the appointment due to being in pain in the same knee, then the notes should show that the PA spoke with/evaluated the patient again regarding the pain and decided to do another injection. If that is the case, then it's appropriate to include an E/M code with the injection. Hope that helps!

 

[jnieto625]

Thanks