Wiki Office Visit with an injection/procedure??

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sadieandbrian

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I'm sorry, I know this has been a topic before...but I am looking for some help or some guidance regarding this.
We do billing for a pain management physician. Our office clinic is located within the same building as the procedure clinic where he does his injections, nerve root blocks, facet blocks, etc.
So my question is...if he sees the patient in our office clinic for say back pain & then takes them over & does any of the above procedures on his back...can we bill for the office visit?
My view is "no", it's included in the procedure. But others have said it needs researched to see if that was the reason for the appointment in the first place, etc. I'm thinking it shouldn't matter...the office visit is included in the RVU's for the procedure, so no separate office visit should be billed. (I do understand that if besides the back pain, he also did an exam for say a sore knee...THEN the office exam could be considered separate).
Any & all help is appreciated!! Thanks!
 
If the injection is done related to the original E/M reason for visit, it is included.

If, however, they physician offers an injection during the E/M exam for a "different diagnosis," you can bill for the injection.

I usually tie the E/M to those diagnoses, and link the injection to a seperate (but med necessary per the LCD), and attach the 25 mod to the E/M
 
Is it an established patient and is this the first time patient has been seen for back pain?
 
Sorry for late response. It varies, both established patients & New Patients. I would say 70% of the patients he sees in the office (rather estab or new) are then taken over for a procedure on the same date.
 
sadieandbrian said:
I'm sorry, I know this has been a topic before...but I am looking for some help or some guidance regarding this.
We do billing for a pain management physician. Our office clinic is located within the same building as the procedure clinic where he does his injections, nerve root blocks, facet blocks, etc.
So my question is...if he sees the patient in our office clinic for say back pain & then takes them over & does any of the above procedures on his back...can we bill for the office visit?
My view is "no", it's included in the procedure. But others have said it needs researched to see if that was the reason for the appointment in the first place, etc. I'm thinking it shouldn't matter...the office visit is included in the RVU's for the procedure, so no separate office visit should be billed. (I do understand that if besides the back pain, he also did an exam for say a sore knee...THEN the office exam could be considered separate).
Any & all help is appreciated!! Thanks!
Click to expand...

It depends entirely on whether the injection was planned prior to the procedure, or not. If the physician evaluated the back pain, then decided to do the injection as a result of their evaluation, then the E/M is separately reported, with modifier 25 (see definition of modifier 25, for more information).
If the physician knew that he was going to do the injection before the patient walked into the office, and did a limited evaluation prior to the injection (much like a pre-op visit, for a scheduled surgery), then the E/M is not billed separately. Hope that helps! ;)
 
Minor procedures include the assessment and decision for the procedure. This includes new patients. Medicare is very clear on this, as is the AMA. I would suggest that you refer to the description of the 25 modifier in the AMA's Coding with Modifiers. That being said, if the patient were to have co-morbidities with or without medications or previous history that indicates the need for extensive or comprehensive evaluation and/or medical decision-making that encompasses more than that required for the procedure prior to performing it, that is above and beyond the normal scope of inclusion to the service provided. The decision to use the 25 modifier is not black and white, always with this - never with that. It is dependent on each individual case. Doing a full history and exam prior to performing a minor procedure as a matter of course on every patient and billing the OV with a 25 modifier, using the reasoning that it must be done to assess the issue for treatment is a misuse of this modifier. It is not a substitute for the 57 modifier (decision for surgery) for minor procedures.
 
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