Level of EM


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Please help me with this PT.

Pt is known to have both meniscal damage as weell as arthritis to her right knee. She suffers from Parkinson. She is limited in her ambulatory activities secondary to that and more recently with her knee discomfort. she has had a injection back in Nov. She normally receives an injection perhaps one to three times per year over the last several years.

Her knee today is consistent with previous examinations.

After Bedadine prep her knee was injected with 3-4cc Lindocaine adn 2cc Depo-Medrol 40, which she toerated well. She will follow up.

Can I bill level 3? She is a established PT. Thanks

Here is another one I would like to know what to bill with and injection.

Pt is known to have right osteoarthritis. She has had a previous injection in March of last year and noticed relief and a comfortable feeling to that knee up until more recently.

Her right knee exam today shows no swelling or soft tissur effusion. She has diffuse medial greater than laterl sided tenderness. Medial side pain with deeper flexion. Her quad strength is 4+ to 5. She has normal sensation to light touch. Hip range of motion is comfortable. There is no brusing redness or warmth.

After sterile prep her knee was injected with 3-4cc Lidoccaine and 2cc Depo-Medrol40 whichshe toterated well. She will follow up.

Thanks so much for helping.


True Blue
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I have time to do the first one real quick ...

mod factor -- injections, modified ambulatory activities
right knee -- location
1 ROS -- musculo (arthritis)
PMH -- significant for parkinson's
expanded problem focused

est problem, worsening
moderate risk
low MDM

that gives me a 99213-25 + your injection & J code (don't know off the top of my head)
Milwaukee WI
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Did patient come FOR injection?

If the patient was scheduled for the injection, then no separately identifiable E/M at all.

F Tessa Bartels, CPC, CEMC