Wiki Injection done on same day - risk category

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mhughes0301

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Hi everyone!
It is my understanding that an injection done on the same DOS as an e/m does not fall into the risk category.
The patient came in for a re-eval of his rotator cuff syndrome. The plan is "Today, he elected to go ahead with an injection. Risks and benefits discussed in full detail. After that, under aseptic conditions, he had received 80 mg of Depo Medrol and 2 cc of Marcaine .5% in the subacromial area with excellent immediate relief".
It is my understanding that since we are billing for the injection as well as the E/M- the injection can not fall into the risk category. I just wanted to confirm this was correct.
Thank you so much!
 
I found this on Noridian.
Q8. Can we always give a moderate level of risk using the example of "prescription drug management" when we order an injection for the patient?
A8. Ordering an injection for the patient is not prescription drug management. There can be many different reasons for ordering injections including, but not limited to, birth control, cancer treatments, joint issues, allergies, and antibiotics. The column of risk is "Risk of Complications and/or Morbidity or Mortality of Patient Management." The MDM table includes examples of situations that could fall under that category of risk. The AMA definition of morbidity reads "A state of illness or functional impairment that is expected to be a substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment." The AMA definition of risk reads in part: "The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of event under consideration." "Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified healthcare professional in the same specialty." "For the purposes of MDM, level of risk is based on consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter." Choose the level of risk based on the physician or other qualified health care professional's determination and documentation of the risk to that specific patient for that specific encounter for that specific treatment choice. Documentation in the medical record must support the decision for the treatment to bill for the administration of the injection and drug.
 
Respectfully disagree with counting it as a prescription drug management under the risk element for the E/M when talking ortho. Joint injections are minor procedures. If there was no patient specific risk documented, it would fall under low in the risk column; decision for minor procedure (surgery) without identified patient or procedure risk factors. If the patient has DM and is getting the same Depo injection it *might* warrant w/ pt. risk if documented.

Other places it was discussed: (This first link has a doctor opinion about it) https://www.aapc.com/discuss/thread...edures-ortho-pm.200021/?view=date#post-548273 https://www.aapc.com/discuss/thread...joint-injection.202507/?view=date#post-554983 (Older discussion/debate we had about it) https://www.aapc.com/discuss/thread...drug-management.191241/?view=date#post-554882

As always, you have to look at the whole encounter note. As an example, what was the rest of the note like for your example? Is this an older patient with chronic shoulder pain that has no other problems? Have they been managing with repeat injections over time? Is this an established patient with a well-known problem to the provider and no other health issues? Did they do anything else at this visit? It's not going to be moderate (4) if that's the case. I might even go so far as to say no E/M should be charged if the sole purpose of the visit was to come in for a repeat injection. This happens a lot with knee OA patients trying to put off surgery. Was this the patient's first injection for the problem? Did they just suggest OTC meds like ibuprofen? PT? I audit all day every day and I cannot even count how many ortho visits are billed as 4s that should be 3s because it was injection-only with nothing else. Even if they do an XR, if the XR was billed/paid in-house you can't double count it in the data. This is especially true if it is one of those follow-up w/ the PA injection clinic only type visits and the PA bills a 4 on every single one.

A different example might the same pt/problem yet they are a new patient; chronic exacerbated, carries in an outside MRI, the provider documents MRI independent interpretation, gives the same injection. This would make Mod/Mod/Low - 4.

Edited to add: I am specifically talking about joint injections in office. Ordering a TFESI, RFA, Facet , MBB, etc. is different because they are not necessarily doing them the same day as the E/M in the office. Also, if you have Rheumatologists in office this is different when talking about things like Tymlos, Prolia, etc.
 
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