Wiki Joint injections with office visit

[jatownsend]

I have a physician who believes that he must down code his office visit when he gives an injection to the patient on the same day. This is a patient who came in with knee pain and then it was decided to do a joint injection. Any documentation to give to him would be greatly appreciated. I have searched several places with no real luck.

 

[mitchellde]

Tell him that the visit level must be supported by the documentation... always. You never down code or up code (except for counseling). As long as his documentation supports the issue of significant and separately identifiable and you have a procedure notation then it is fine. If they return for a planned second inject then you know you may not bill an OV.

 

[FTessaBartels]

Separate paragraph for injection/procedure

What I tell my docs is to document their E/M service and then add a separate paragraph entitled: Procedure: Injection ( or whatever they did). Then to describe what was done in that separate paragraph.

Our Compliance department has agreed with this approach for minor procedures that don't require a trip to the OR or procedure room for anesthesia.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[mitchellde]

I totally agree that is what I have my docs do. Also with a joint injection and the first encounter I make sure the physician documents the examination of the unaffected joint. This is one of the thing that helps support the E&M as significant, and so many of the physicians I have worked with "forget" to document this examination.