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code a level 2-99212 w/the injection?

  1. #1
    Default code a level 2-99212 w/the injection?
    Medical Coding Books
    Patient is here for follow up on her right knee degenerative joint disease. She is interested in repeating the synvisc injection. She had one last summer that significantly helped until the past week. Denies any changes in her general health.

    After routine prep I injected the right knee with synvisc-one. She tolerated teh procedure well and was given instructions for that. She is to follow with us as needed.

    Patient hasn't been in for a year. He has one CC, one body area- the knee and MDM. Thoughts???


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  2. #2
    Location
    Austin, Texas
    Posts
    467
    Default
    The billing/reimbursement for the CPT of synvisc injection is supposed to cover the minimal exam as noted above, and without sufficient documentation on physical exam for range of motion with flexion, extension, pain complaints with severity/duration/alleviating factors, then no E&M should be billed, in my opinion.
    Marcus Murphy, CPPM

  3. #3
    Default
    Works for me! Thank you!!


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

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