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Injections and E/M Code Modifier

  1. Default Injections and E/M Code Modifier
    Medical Coding Books
    If the patient is scheduled for an injection 20610 and the Physician performs a complete examination of the patient. We charge the appropriate level E/M do we need to modify the E/M with a 25?

    My Physician is Telling me since the patient was scheduled for the injection that a Modifier 25 cannot be used. However she performs a complete exam with the patient and her documentation shows this.

    I think we should modify the code, I need some advice!
    Thanks!
    -Tori

  2. Default
    In this case i would check whether the E&M service was medically necessary for the patient before injecting and no matter whether patient was scheduled or not. Even for the same diagnosis for an E&M with a procedure on same day we can bill the E&M with a 25 modifier. No CPT guidelines restrict this.

    From my point of view if you have a clear medical documentation of the E&M service which shows its significant then you can attach a 25 modifier.
    Dr.Raja CPC
    Coding Auditor

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default E/M must be Significantly SEPARATE
    To correctly use the -25 modifier, the E/M service should be not only significant, but also significantly SEPARATE from the procedure (in this case the 20610 injection).

    The RVUs for procedures include some examination / evaluation of the patient as a part of the procedure.

    Perhaps your physician believes that while the exam was well documented it was not over and above what is required for this procedure. If that is correct, then she is right ... the E/M service is NOT a significantly separate service so should not be coded.

    If on the other hand, the history, exam, etc in this case went beyond what was required for the injection (perhaps the patient had other issues beyond the joint problem that required the 20610), then you have a significantly separate E/M and can code that service and use the -25 modifier.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 01-09-2009 at 10:15 PM.

  4. #4
    Default
    I agree with F Tessa. The e/m doesn't need to be "significant" but rather "significantly idenitifiable and separate" to the same dos procedure being rendered.

    Hope this helps...good luck!
    Sylvia Thompson, CPC
    Billing Supervisor
    San Diego, CA

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    If the patient was scheduled for the injection then an E/M should not be coded - unless of course the E/M meets the "significant, separately identifiable" definition.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Location
    St.Petersburg, Fl
    Posts
    46
    Default
    Did the Dr. actually give the injection?? He usually just orders it and the nurse gives the injection, from my experience you don't use the 25 modifier for injections because it's the nurse that administrates it.
    Alecia Peck CPC

  7. Default
    Thats a blind guess!!! Nurses won't give major joint injection (20610).

    My opinion is to check with the medical records whether the E&M service is distinct and if its you can use 25 mod. otherwise leave it off..
    Dr.Raja CPC
    Coding Auditor

  8. #8
    Question E&M with 25 Modifier with Injection
    Help me clarify how you distinguish significant, separately identifiable service. I have a new patient who comes in with pain and stiffness in a joint. The Dr reviews symptoms, does the PFSH, an exam, xrays and then discusses options with the patient. The decision to give the injection was made by the patient. Can we bill the E&M and 20610? Previous chats indicated that even if the patient is new, an E&M is built into the 20610 or any minor procedure for that matter.

  9. Default
    I realize this is an old thread, but I to would like to know what Lynnsherwood asked. The part that is confusing me mostly is that if I can't bill both the E/M and the injection and can only bill the injection, we get paid less for doing more. Normal office visits for a new patient are being coded as 99204 as of right now which has a much higher RVU than 20610. So if my Doctor does and E/M and no injection he gets paid more than if he does an E/M and injection because he can only bill for the injection?

  10. #10
    Default
    Quote Originally Posted by lynnsherwood View Post
    Help me clarify how you distinguish significant, separately identifiable service. I have a new patient who comes in with pain and stiffness in a joint. The Dr reviews symptoms, does the PFSH, an exam, xrays and then discusses options with the patient. The decision to give the injection was made by the patient. Can we bill the E&M and 20610? Previous chats indicated that even if the patient is new, an E&M is built into the 20610 or any minor procedure for that matter.


    If this was the office I currently work for, the coding for a new patient with the documentation you've given me would be:

    99203-25 (if the dictation was thorough you may be able to get 99204)
    20610(major joint) or 20605(medium) or 20600(small) with laterality modifier
    J1030 or J1040 depending on usage and amount


    However, if this was an established patient who was being seen for a scheduled follow-up with a plan for an injection, the normal coding would only be for the injection procedure and the substance injected if it isn't already bundled into the procedure code. Also, for this scheduled visit, don't forget to add the Dx.


    Peace
    @_*
    Hope this helps. I work at an ortho clinic.

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