I agree with Lisa, up until two weeks ago, I worked for a very large ortho practice and you cannot bill for the lidocaine, you should bill the joint injection (20610) with the kenalog (j3301) and that's it. As far as the modifier 25 even if the doctor did the medical decision making for the e/m and the patient agreed to the injection, you cannot bill the e/m unless you evaluated the pt. for some other problem (hence modifier 25 which stipulates separately identifiable e/m service). Say for example the pt. presents complaining of knee pain and wrist pain, the doc. may decide to inject the knee and just watch the wrist, well in that case you could bill the e/m with modifier 25, but if the pt. simply presented with knee pain and the doc. decided to do a knee injection, you could only bill the injection and the drugs.