Wiki Office Visit and Injection Bundle

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urbach34@yahoo.com

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Our follow-up ladies have brought a few office visits to me that insurance is denying payment. They are denying the office visit as bundled. An example of what we are billing is as follows:

99213-25 (M17.12, M25.562) *DENIED*
20610-Lt (M17.12, M25.562) *PAID*
J1040 *PAID*


Are we unable to bill an office visit when the dx is the same for both the office visit and the injection?
 
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I wonder if they are concerned with so many people billing E&M w/ injection when the patient is only there for the injection so they are just rejecting everything? The insurance company I work for, this combo isn't having any issues.
 
one thought....were these procedures scheduled prior to the services rendered? If so, then no, you cannot expect payment for the office visit unless significant extra work was done in addition to the procedure itself, or other issues addressed that are "significant". Carriers are becoming more strict in how they process/pay these procedures. If the notes do warrant billing an office visit with the procedure, follow up with your carrier as to how they want you to proceed.
 
If it's an established patient with an established problem, the injection is what should be billed. If it's an established patient and this is a new issue then you can bill the EM and injection because the doctor probably had to examine the patient in order to come to the conclusion to do the injection. If you have documentation to support that an office visit was necessary, then you can appeal it.
 
I have been getting a ton of denials for office visits billed with injections from Humana. If I look over it again and see that the note suggests the injection was already planned, then I drop it. But some of these I appeal and feel like i give pretty good reasoning and they STILL deny. It drives me nuts because they aren't coders but tell me I can't bill for an office visit, so I can't really explain my side of it. Just got two letters this morning from them saying they're sticking to their original decision. It's just so frustrating :/ Maybe I'm totally wrong, but they're also not helping either hah.
 
You might check to see if the denial trend is from a specific payer. If so, I would research the payer's website or just call them to see if they have recently changed their payment policies on these code combinations.
If the documentation truly supports what is being billed, exhaust any/all of the payer's reconsideration/appeal processes. Suggest a way for the follow-up staff to track the accounts they appeal so it is all done timely but also to make sure the payer is responding timely.
 
If you are going to be successful in these appeals you need to show in the documentation, that part of the assessment that is over, above, and beyond (separately identifiable) what is necessary to give the injection, and yet still pertinent (significant) to why the patient is there. Every procedure including injections has as a part of that procedure, the assessment necessary to perform all elements of the procedure. So assessment of the area to be injected is part of the injection. Is there any other part of the documented assessment that is not part of the area to be injected and it still pertinent to why the patient is there. If you can do this then an appeal is usually more successful.
 
This is the note:


CHIEF COMPLAINT
81-year-old female with complaints of right knee pain.


REASON FOR VISIT
Patient is seen and assessed today with regards to her right knee. She has had a recurrence of her right knee swelling and she is concerned about this. She says that the knee generally feels better, but it is tender. When I asked her about her knee, she says that it swells, and it is markedly swollen. She says that it does not lock. She has pain over the joint itself, it does not buckle out from under her, it does not snap and pop, range of motion is about 2 degrees and she cannot really bend it much past 90 degrees without experiencing pain because of tightness, she says because of swelling in the joint. Activities such as walking are limited, the limb feels weak and it gets stiff when she stands from a seated position.


HISTORY OF PRESENT ILLNESS
Patient is an 81 year old female.
• Medication list reviewed.


CURRENT MEDICATION
Patient takes no medications.


PAST MEDICAL/SURGICAL HISTORY
Reported:
Surgical / Procedural: Surgical / procedural history Gallbladder Surgery.
Diagnoses:
Hypertension.
Rheumatoid arthritis
Total Knee Replacement, left.
Surgical:
• Tonsillectomy with adenoidectomy
• Hysterectomy


SOCIAL HISTORY
Behavioral: No tobacco use and smoking status: Unknown if ever smoked.
Alcohol: Alcohol.
Drug Use: Not using drugs.
Marital: Widowed.


ALLERGIES
Patient has no known drug allergies.


FAMILY HISTORY
Hypertension
Arthritis


REVIEW OF SYSTEMS
Systemic: No fever, no chills, no recent weight loss, and no recent weight gain.
Head: No headache.
Otolaryngeal: No epistaxis.
Cardiovascular: No chest pain or discomfort, no palpitations, and the heart rate was not fast.
Pulmonary: No dyspnea, no cough, and no wheezing.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, and no hematochezia.
Genitourinary: No hematuria and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia and no excessive sweating.
Hematologic: No easy bleeding and no tendency for easy bruising.
Neurological: No vertigo and no convulsions.
Psychological: No anxiety and no depression.
Skin: No rash and no sore:


PHYSICAL FINDINGS
On physical examination today, the patient is a cooperative, orientated, pleasant, 5 foot 4 inch, 122 pound, 81-year-old, female. Examination of her right knee reveals a rather tense effusion.


TESTS
No new x-rays were taken on today's visit.


ASSESSMENT
Right knee osteoarthritis primary
Right knee effusion.


PLAN
I elected to aspirate and inject her knee here today and did so under sterile conditions. I prepped the right knee with Betadine and alcohol then utilizing ethyl chloride as an analgesic I passed a 22 gauge needle into the joint utilizing a lateral approach on the lateral side of the patella and proceeded to aspirate 70 cc's of straw colored fluid. I discarded this as it certainly did not look infected. I then injected 40 mg of Depo-Medrol and 3 cc’s of Xylocaine. The patient tolerated the procedure well. A Band-Aid was applied. We will reassess on a PRN basis.
 
That documentation does not support billing a separate e/m service in my opinion.
 
why though? that's what i want to know. if we can't bill for a visit, that's totally fine, but i'm obviously missing something
 
There is nothing in the note that is significant or separately identifiable from the exam for knee pain and the decision to inject the knee. This is the same note you would get if this were a planned injection.
 
So. If this patient was seen for this arthritis in the knee for a while, but if this visit was bursitis instead, then we could charge for a visit? Since it's something new? But if this patient was seen for the arthritis anytime and gets an injection now we can't charge for a visit since it's a known issue? Like we can't charge for a visit ever for the OA if they get an injection? I'm sorry if I'm getting crazy with the questions, I just haven't found anything that explains different scenarios of when and when not to charge.


Thank you all for your input, I appreciate it.
 
There just is not enough to justify the components of the 25 modifier. The assessment provided is exactly what was needed to perform the procedure. It would not matter if it was a new diagnosis or even a new patient. Let's say the patient chief complaint was a painful knee, and the provider decided to look for what might be causing this pain such as a spine mis alignment or hip issue. Something along that line, or evidence of some other injury cause the patient to overuse that joint. Or if the patient had a new complaint in addition to the knee pain. The ability to support an assessment that is significant and separately identifiable is extremely hard. It is not just performing an exam of other areas but why was that exam needed at this time, how is it relevant?
 
Thank you so much for explaining this. I didn't realize that this was more tricky than I already thought.
 
I would want more information to determine if an E/M is bundled or not

The fact that there is no X-ray really leads me to believe that the patient has been treated for this condition previously. It seems the patient is returning with continued pain. Many times our patients are told: If this does not work, we will try an injection on the next visit. Was this the "next visit"?

Normally an E/M would really be justified if this was a new or significantly changed problem, and there was no previous plan or talk of injections.

Don't look at this one note to make the decision, look at previous visits and see where this office visit fits in, your answer is probably there.
 
If you don't see them for any other problem but the problem they are doing the injection for they won't pay unless it's the first visit
 
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