Wiki Injections and E/M

[ncalderon]

Please help I am confused example
Patient is scheduled just for a follow up visit for knee during the exam has increase pain in knee which is documented steroid injection was discussed and documented as a separate office procedure. Do we bill just an office visit? Do we bill just the injections? Thank you

 

[iowagirl77]

This can be a tricky call sometimes. If this is the first injection, you can bill both the E/M and injection. If this is a repeat injection with nothing else evaluated and no change in plan of care, I'd bill just the injection. Sometimes my providers will document the patient has worsening pain, but all they really meant is that the last injection has worn off so the pain has been getting worse due to that. That would not constitute a separate E/M. If there are other issues being evaluated or a new injury (not just an exacerbation of the condition brought on by too much activity), a separate E/M may be warranted.

A couple of articles on this:
https://www.aapc.com/blog/27185-use-caution-when-reporting-same-day-injection-and-em/
https://www.aapc.com/blog/27690-know-when-to-bill-em-with-a-minor-procedure/

I hope that helps!