Wiki Office Visit and Injection

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PCMOS

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If you are seeing a NP in your office and give an injection on that first day is there is a way to get paid for the OV and the injection? I dont have separate/distinct dx codes to use modifier 25
 
State the reason for the injection. Pain is good enough as long as it's documented.

Peace
@_*
There has to be a Dx in the dictation otherwise, it didn't happen.
 
PCMOS said:
If you are seeing a NP in your office and give an injection on that first day is there is a way to get paid for the OV and the injection? I dont have separate/distinct dx codes to use modifier 25
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He is billing 20611 for the injection. Dx codes are M75.41, M75.21 adn S46.011A
 
Does the documentation support a new shoulder injury separate from the shoulder impingment and the tendenitis? you used the A as the 7th character on the injury code which would indicate this is the active treatment encounter for a shoulder strain. or is the other issues related to an earlier shoulder strain and this is not active treatment? You do not need separate codes for an office visit to be payable in addition to the procedure. However it looks like you have incorrectly linked your diagnosis to the procedure. You would not perform a joint injection for biceps tendentitis. I also have not ever observe a joint injection as the active treatment for a shoulder strain. So what doe the documentation state is the reason for the injection? what was the substance of the office encounter if you extract the necessity for the injection? I can make theories but there is no way to really know how it should be coded without the actual note.
 
Thanks Michelle. I think there was miscommunication on my part as I had not linked all those codes with the injection code, I was just listing all the dx codes the provider had listed in the note. I will get more information from him and decide on the office visit coding. Thanks for all your information.
 
Those Dx are valid just have the doctor document for which issue the injection was for (Dx pointer) and also where he injected specifically in the shoulder region.

Peace
@_*
 
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