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Pain patient admitted post procedure

  1. Default Pain patient admitted post procedure
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    Patient had lumbar epidural steroid injection at an ambulatory surgery center. He experienced numbness in his legs. The surgery center transferred him to an emergency room, the numbness did not subside and the patient was admitted to the hospital. How do I code the admission? I have never encountered this and am not confident about a code for this. Thanks!

  2. #2
    IF your physician is the ADMITTING/ATTENDING then you would bill 99221-99223 for the admission if inpatient or 99234-99236 if observation.

    If your physician was not the admitting and services were rendered you may have an inpatient/outpatient visit or consult depending on the documentation.

    For any of these scenarios you would need to add the -25 modifier to the E&M service occurring on the same date as the epidural steroid.

    Julie, CPC

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