Wiki injection only to be billed out?

[trose45116]

I don't see anything coming out to be able to bill the E/M with the injection. any thoughts?? I am still trying to understand and learn the E/M. its fairly new to me.


1. Right knee pain.

HPI:
Appointment type:
Established patient - Established problem Patient returns for his right knee. We last aspirated his calf in early December this helped him significantly. He is interested in possibly injecting his knee. He denies any other complaint.

ROS:
no change from 12-09-15.

Medical History: Diabetes, heart attack, hepatitis.

Surgical History: heart stents .

Family History: No Family History documented.

Social History:
tobacco- no
alcohol- no
married.

Medications: Taking Aspirin , Taking Lisinopril , Medication List reviewed and reconciled with the patient

Allergies: N.K.D.A.


Objective:

Vitals: Wt 170 lbs, BMI 27.44 Index, Ht 5 ft 6 in.

Physical Examination:
Examination of the right knee shows no evidence of skin abnormality. He does have swelling on the patellofemoral Crepitus. Pain with palpation medial femoral condyle. No lateral sided tenderness. Relatively full knee range of motion. Knees ligamentously stable. Normal motor sensation pulses and skin examination distally.


Assessment:

Assessment:
1. Arthritis of right knee - M19.90 (Primary)

Plan:

1. Arthritis of right knee
Notes: Patient was taken to the procedure room. Under ultrasound guidance, 2 cc of Kenalog and 4 cc Marcaine was injected into the right knee. Patient tolerated this well. All questions were answered.


Procedure Codes: J3301 Inj, triamcinolone acetonide 80mg, 20611 INJECTION JOINT/BURSA/DRAIN W/US

Follow Up: prn

 

[erjones147]

To me, the key phrase is in the HPI: "he is interested in possibly injecting his knee."

Based on what you posted here, it seems that his C/C was knee pain, the doc examined, and then a decision was made to inject - the patient did not present with the sole purpose of receiving an injection

I would code both the E/M and the injection

 

[thomas7331]

I would not code an E&M in addition to the procedure for this encounter. The decision to perform the procedure alone is not sufficient to justify a separately identifiable service. CMS states that "where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure." In this note, there is no new problem or change in the patient's condition since the last visit, other conditions being treated and no new data reviewed or tests ordered, so I think it would be hard to defend a modifier 25 in this case.

 

[philipwells]

I think the change from the last visit to this one was that the pain was initially in his calf? Now it's his knee? I'd say that's definitely a change in the patients condition from the initial injection.

I love my profession but the amount of conflicting information is almost overwhelming at times.