Major Joint Injection Billing

kkindle1807

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Belton, MO
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This is more of a billing question.

Does anyone know if one chooses to bill an Injection code (20610), if the E/M pays more?
So just billing out 99213 and the J3301 (Kenalog), instead of 99213 (25 mod), 20610 and J3301.

Does anyone know?
 
If you do an injection you need to bill for it, you can't just lump it all into an EM code. It's also highly unlikely you would be reimbursed for the J code without the injection code also. If your documentation supports a separately identifiable EM service above and beyond the usual preoperative and postoperative care associated with the injection, then you should bill the EM service with the injection code and medication code. If not, you should only bill 20610 and J3301. Just because you do an injection does not mean you automatically get to bill an EM service with it, that goes for new and established EM visit codes. You don't bill based on what pays more, you bill based on the services documented and supported.
 
Agree with Marissa above, to be sure.

This is a loaded issue, as many payors, starting with CMS, have tried for years to argue that there is enough overlap in work between the E&M associated with the visit and the work of the injection that they should somehow be bundled. That is entirely inappropriate. CPT has established, as has CMS, what E&M work is associated with the injection itself - it includes the decision to move forward with the injection, the discussion of risks/benefits and the discussion of post-procedure care. That's it. The work of the injection DOES NOT include the evaluation of the patient, consideration of alternative diagnoses, consideration of alternative treatments, etc. IF that work is being done, and being documented, that is a separate and identifiable E&M service, per CPT. That needs to be broken out with a -25 modifier.

-25 Modifiers have had a target on their back for years, stemming from a 2018 CMS PFS Proposed Rule that was NOT finalized. Several third party payors have taken that proposed rule (which, to be clear, is NOT CMS POLICY, it was a proposed-and-rejected policy) as justification for trying to deny E&M on the same day as an injection. If that is happening, as long as the E&M is well documented, it should be appealed fervently. If any coders out there are allowing these claims to be rejected, you are going against established CMS and CPT policy and doing your physicians a grave disservice. Persistent denials of -25 modifier associated E&M should be brought to your state's insurance board.

You should NEVER choose between billing out an injection OR an E&M if they are both documented. They should both be billed, and they should both be paid. Anything less violates CPT and CMS policy and claims standards.
 
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