Wiki Repeat Injections with E/M Codes


Charleston, West Virginia
Best answers
Greetings Fellow Coders! :)

Scenario: A new patient is evaluated and found to have OA of the left knee. On that visit, the physician decides to perform an injection and bills an E/M (99203) with a modifier 25. At that visit, the physician does not "plan" another injection.

If the patient returns three months later
and the physician decides to perform another injection at the time of that visit, can an E/M be billed? If not, under what circumstances could an E/M be billed? (For example, if the drug and/or dosage changes, if the condition worsens, if "X" amount of time has passed, if x-rays and/or other imaging reports are ordered/ reviewed, etc., would any of these factors allow for an E/M to billed?)

Thank you all in advance,

Under these circumstances it's normal not to plan another injection. The doctor is going to want the patient to follow up and will find out then if it worked, if so for how long, not work at all. You don't normally plan another injection in this case. Keep in mind that O/A is a chronic condition and you don't expect it to "improve" like you would other medical conditions. You can treat the pain but the condition is going to progress over time. Also keep in mind that every surgical procedure code, yes even the lowly 20610 has a "built in" E/M component to it. You would have to review this on a case by case basis but once someone has O/A and you know its going to progress (the only question will be how fast), how much medical decision making is needed to have another injection? In this case usually not much. A change in the medication used or the amount may play a part, and may support a separate E/M depending on the circumstances especially if the patient gets almost no relief from the initial injection.
When a patient receives an injection, you typically cannot bill for an E/M for six months, unless the patient is being seen for an unrelated issue.
When a patient receives an injection, you typically cannot bill for an E/M for six months, unless the patient is being seen for an unrelated issue.
Hi! Is the 6 months time-frame a MCR guideline? Can you provide a reference?
Thank you!
It all depends on the work of the visit. If the sole purpose of the return was an injection, even if they may not have "planned" to do it, you won't code an E&M. In many cases, Orthovisc for example, they plan a series of 3 injections. So in that case it is actually planned ahead of time. Orthocoderpgu gives good advice. There is a component of pre/intra/post service work built into the RVUs for procedures (in this case 20610, 20611, etc.) so you can't also get credit for the same work by billing an E&M.

Your reference is the coding guidelines and definition of Modifier 25 (significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service) and the office/outpatient E&M guidelines.

Not sure which MAC you may be billing to but here are some references: