If the intent of the visit was a scheduled injection in a series and there are no new or different complaints/diagnoses you can't bill an E/M-25 with it. Monovisc, Orthovisc, Hyalgan, etc. Your provider is putting themselves and the practice at risk doing this. It does not qualify for a 25. It was a planned procedure. They already got credit for making that decision and planning for the injections at the prior visit where an E/M was billed and the decision was made.
Do you have an example of the cross out method, or would it be possible to attach an office note example. My providers are adamant that when an established patient is receiving repeat injections, that they have had in the past, they are reevaluating, conditioning is worsening and they are recommending otc, which would fall as a level 3. This is where the confusion is coming in, if the patient was not receiving the injection, they would still qualify as a level 3. Thank you for any advise.
We may be touching on two different scenarios. In one, the patient has already been seen (recently) and they decided on a visco injection series, injections are scheduled and that is the sole purpose the patient returns.
Thank you so much for your input.We may be touching on two different scenarios. In one, the patient has already been seen (recently) and they decided on a visco injection series, injections are scheduled and that is the sole purpose the patient returns.
In the second (which I think is what you are talking about) is an established patient comes in with worsening OA/pain. The provider re-evaluates and decides on either visco or maybe cortisone to be given or started at that visit. In this case it may be entirely appropriate to code the E/M & the 25. That's why initially I said it depends on the documentation. Each of these would have to be taken on a case by case basis. In many cases patients are managed with OA for years before they finally end up with a TKA or THA or TSA depending on the joint.
Maybe a patient had come in last year or 6 months ago, has been managing with OTC meds but now it's getting worse and it's time for injections. It would make sense to see an E/M and injection at this point because it has been so long since the patient was last seen. There could be health status or other changes that have to be considered, they may need new Xrays. On the other hand, maybe the provider saw the patient a week or two ago, they tried OTC but also talked about injections, it still hurts, they come back in and get an injection. Has anything changed, was the note exactly the same except now says, yup let's give you an injection (like we talked about a couple weeks ago)?
There is no 100% yes or no, it depends on the encounter. However, if it is for a #2 or #3 in a Visco series, it's more than likely a hard no (unless something else is wrong and evaluated/managed). I know people always want a black and white answer but it's not possible
Some of these may help:
I don't have any notes. If you can print one out just take a pencil and cross out anything related to the H&P (pre-service), actual administration of the injection (intra-service), and post procedure result/directions (post-service). That is all work that is counted toward the 20610/20611.
Thank you for this input, amyjph, it's really helpful. I checked my local MAC's LCD for any definitive statements such as the ones you've provided above and unfortunately, they don't include such, so it's been hard to give the providers that definitive proof to really enforce what I'm trying to tell them. I will keep trying at it. It doesn't help either they are chronic copy & pasters when it comes to the encounter notes.
You're welcome.
Much appreciated! Thank you for these resources.
Amy, I know this is an older post, but I have some similar questions. I have reviewed Medicare's rules and AMA's guide on modifier 25. My question is, do x-rays count as significant and separately identifiable, or are they considered to be apart of the "assessment of the problem area to be treated by surgical or other services"?
Is the provider being paid separately for TC/26 or global fee of the X-Ray performance on the same date? How will the documentation justify appending a 25 modifier and getting paid separately for an E/M, two injections, and the separately paid X-Rays on the same date?
Thank you. I'm pretty confident in coding E/M services with minor procedures when there is a new problem. The follow-up office visits with injections are what confuse me. Most of the time, I find that the E/M procedures are not billable with injections. However, there are still a few incidences that have me questioning my understanding of what constitutes and E/M service as significant and separately identifiable.