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Medicare and Injections


Madison WI Chapter
Best answers
We have an outsourced billing co that does our surgery coding an payment posting. They also keep us in the loop of changes and/or heads up on billing for the clinic. They recently stated that MC has clarified the Evaluation and Management on the same day as a Minor Surgical Procedure as seen below:
Evaluation and Management on Same Day as a Minor Surgical Procedure
Chapter 1, Section D
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for this procedure
Revison date (Medicare):1/1/13
The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is reportable with modifier 25.The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient , the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M on the same date of service as a minor surgical procedure.
Our Billing Co initial interpetation of this is below:
Although Medicare has clarified that an E&M service on the same date
as a minor surgical procedure is included in the payment for the minor surgical
procedure, the criteria for billing the E&M separately from the minor surgical
procedure has not changed. If a “significant and separately identifiable E&M
service UNRELATED to the decision to perform the minor surgical procedure…”
is performed, then the E&M service is separately reportable with a 25 modifier.
We believe that this is more of a clarification than a change in policy. We strongly
suggest that the documentation for any E&M service billed with a minor surgical
procedure must contain a high level of detail to ensure that the medical necessity
of the E&M service passes the “Significant and Separately Identifiable” litmus test
and that the medical decision making includes more than just the decision to
perform the minor surgical procedure.
Please note that the fact that a patient is “new” does not constitute an
exception to this policy.
No suprise, our doctors are not happy with this as it affects all of our steroid injections. Which in the clinic are numerous. One of our Drs asked the question that if one or more of the following were included in the chart notes, he felt an E&M per the wording above was acceptable: Xrays were taken, PT was ordered or work restrictions given the patient,
This was passed along to our billing co for their feedback. See feedback below:
If the Dr orders PT and/or puts a patient on work restrictions, you would be justified in adding the 25 modifier and billing to Medicare (and all other carriers). As for the x-ray, if the Dr addresses the x-ray and any associated pathologies in the Plan/Assessment portion of the E&M, then you can add the 25 modifier and bill to Medicare. However, if the x-ray is negative for any pathologies and the plan simply states:

“x-ray is negative for <fill-in>. Patient will be given a depomedrol injection for pain. Will return in 2 weeks for further evaluation”

Then the 25 modifier would not be appropriate.

Quite simply put, I am not sure this is what MC is trying to accomplish, which is NO E&M code with an injection. Of course I "get it" that if you are addressing a whole different problem the 25 modifer would apply. But if a new patient does not qualify for an E&M code with an injection, I am not sure simply reading Xrays (which we have for almost every injection) ordering PT or putting the pt on work restrictions would qualify for an E&M code either.
Anybody have any thoughts on this? To code or not to code and E&M with an injection.. that is the question
Best answers
Sorry, about that here is the article....

Mind your modifiers: Ortho practices take a second look at use of 25 with minor procedures

by: Laura Evans

Published Jan 25, 2013

If your practice is taking a hard look at use of modifier 25 (Significant, separately identifiable E/M service) with injections and other minor procedures this year, you're not alone.

New guidance issued in the 2013 National Correct Coding Initiative (CCI) policy manual has many practices re-evaluating their E/M documentation and the circumstances when they would separately report an office visit with a procedure (OCPS 1/13).

The biggest problem is identifying what truly is consistently separately identifiable, says Ruby O'Brochta Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist at Twin Cities Orthopedics P.A. in Golden Valley, Minn. “What's above and beyond? There's no standard for that.”

Woodward says her practice will be modifying its coding policies in part because of the strict new CCI language, which states in part that “E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure.”

That rule applies even when the E/M includes the decision for minor surgery, and even when it's a new patient visit, according to the CCI manual.

The only exception: “A significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25,” the manual states. And, “the E/M service and minor surgical procedure do not require different diagnoses.”

The manual then provides this example: “If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent and performs the repair, an E/M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E/M service may be separately reportable.”

You'd separately report the E/M because a full neuro exam is not necessary to stitch up the head wound, Woodward explains. At the same time, though, both the neuro exam and the head trauma are related to the same injury.

That's fine, but “why don't they equate it to our world and use an example when the patient comes in with knee pain?” responds Alison Kuley, CPC, PCS at Litchfield Hills (Conn.) Orthopedics.

In a typical orthopedic case, the patient presents with knee pain and the doctor does a detailed exam of the joint, then decides that the patient could benefit from an injection, which he or she then performs.

Whether they will separately bill the visit and the injection will now depend on a number of factors, say both Woodward and Kuley:

Is it a new patient? If yes, both coders agree billing a separate visit likely is warranted — provided the physician documents it. “You can't just see a patient and not do a workup, especially a new patient,” Kuley says. “You're probably taking X-rays to find out what's going on. That to me is above and beyond a perfunctory exam prior to an injection.”

Says Woodward: “We are not backing off at all on billing an E/M for new patients that we then do an injection on — that makes absolutely no sense. The amount of history, exam and medical decision-making on [a new] patient is well above and beyond the amount required for an injection,” she explains.

A standard pre-op history and physical might include checks of the patient's comorbidities, medications, allergies, etc., Woodward says. But an initial orthopedic exam is much more extensive and comparable to the neuro exam that would be separately billable from the head sutures in CCI's example.

If an established patient, is it an established problem? Consider this scenario, says Woodward: An established patient comes in for knee pain, is examined and is given a list of possible treatments with instructions to come back if he or she is still having problems. The patient returns in a month complaining of recurring pain in the knee, and the doctor decides to try an injection. “In the past, we might have billed an E/M visit with that injection,” she says. “Now, probably not.”

Similarly, if an injection or other treatment has already been scheduled, it would not be appropriate to report an office visit on the same day as the procedure, say both Woodward and Kuley.

What about an established patient with a new problem? “You really have to address it note by note,” Kuley says. “Read the note and make a decision based on documentation” and whether it meets the medical necessity for a separate visit. “You can't tell providers you're never billing an E/M with an injection ever again.”

Medical necessity is ultimately the key, agrees OCPS technical advisor Margie Scalley Vaught, CPC, CPC-H, CCS-P, ACS-EM, ACS-OR. “If a patient presents just for an injection and the documented office visit only fulfills the pre-operative requirements of the injection, you are usually only going to support just reporting the injection code,” she explains. But if they come in and it is not known what they need and an E/M is provided with different treatment options, you may be able to support an E/M.

The new CCI manual information, which has so far not triggered any new CCI code pairs, is just one part of a broader crackdown on practices' use of modifier 25. Both Woodward and Kuley say their Medicare and non-Medicare payers are toughening their payment policies for the modifier.

In Minnesota, for example, Blue Cross immediately denies any level 4 and level 5 office visits billed with modifier 25, says Woodward. Meanwhile, UnitedHealthCare last year began to request the notes to support separate billing of E/Ms with procedures, says Kuley, and “our Medicaid doesn't allow it at all.”