Wiki Procedure / visit sameday


Chanute, KS
Best answers
This happens all the time and I've seen different views from alot of people and I'm still second guessing this, so I'm going to try again.

Can I code both the e/m and procedure for this visit:
Pt comes in with knee pain. Doc evaluates, xrays and gives the patient 2 options: 1. steroid med orally or 2. joint injection. Patient decides on joint injection so doc does it.
Is it correct for me to bill 9921x w/ 25 mod and 20610?
Since the patient wasn't coming in for a pre arranged procedure and the visit is what determined that they needed the procedure and there was more than one management option I woudl say the visit is definitely billable.
I agree. It sounds a though there was "significant, separately identifiable" work done to evaluate the patient's problem. :)