There is a lot of missing information here. Is this patient new to your doctor, or an established patient? If this a new patient bringing the MRI with him, who ordered the MRI and for what reason? Is there a clear history of an injury/trauma warranting a 7 Character S Code, resulting in the knee pain, and resulting in the MRI being done? Or is the patient being seen for knee pain without a history of injury, i.e. an M Code? If this is not a new patient, but is an established patient, and the MRI was ordered by your doctor, then the records should show what diagnosis code was used to obtain the MRI, either an M Code for chronic musculoskeletal condition, or a recent traumatic injury (S Code) needing further evaluation with an MRI. If here is a clear history of injury for which an S Code was assigned, and regardless of whether your doctor was the primary treating physician, or the referring physician, I would consider the patient to still be under the initial evaluation and treatment phase since a new course of treatment was initiated (injection of the knee), and use a 7th character A. If this is not trauma/injury related knee pain (M Code), then it would be an established patient visit, plus the injection code. It must be noted that Hyaluronic Acid (HA) injections are not the recommended treatment for acute knee pain resulting from an injury, but is approved for treatment of knee arthritis (primary, secondary, or post-traumatic). So that needs to be made clear in the records/documentation by the doctor. Your doctor needs to help you clear this up!
Respectfully submitted, Alan Pechacek, M.D.
