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Rules on Injections & E/M Codes please

  1. #1
    Default Rules on Injections & E/M Codes please
    Medical Coding Books
    I would like to know what the general consensus is when it comes to billing injections and E&M visits together.

    It is my understanding that it is allowable to bill for an E&M visit with most injections (like Marcaine for instance) provided the 25 modifier is appended to the E&M code.

    With injections such as Synvisc & Hyalagan (where you know you have a patient coming in for a cycle of shots)
    I was told it was only appropriate to bill the E&M code on the 1st injection~
    and for the remaining 4 in the cycle.....just bill the injection.

    A co-worker of mine was asking whether this is a hard & fast rule though....
    what if the doctor has more extensive documentation?

    Is it ever appropriate to bill for E&M with these more specialized injections?
    Under what circumstances?

    Thanks for your help!

    Amy B.

  2. #2
    there guidelines are (they are written somewhere) that if the injection is scheduled as such, then the E/M is considered an integral part of the procedure.

    The exception to this would be, patient is scheduled for a Synvisc injection in his left knee, but he slept on his shoulder wrong last night and wants the doctor to take a look at it while hes there. Then you have documentation to support the billing of the E/M.

    Hope this helps..if anyone has those guidelines to post (Rebecca?? lol) that would be awesome.

    Mary, CPC, COSC

  3. #3
    North Carolina
    Hello Mary.....

    My Medicare carrier has a nice guideline in place. The codes have changed but the "coding guideline" has not.

    Providers are allowed to bill for an appropriate Evaluation and Management (E&M) service if the decision to start the series of injections is made after evaluating the patient during the same visit. If the decision to inject has been made during an earlier evaluation and the patient is seen for a scheduled injection, an E&M service should not be billed with the injection code. After the first injection, during the visit for the subsequent four injections of Hyalgan or subsequent two injections of Synvisc, an E&M service will not be paid by Medicare unless there was a separately identifiable problem for the service. The -25 modifier should be appended to the E&M code on the claim to indicate a decision for treatment the same day as the injection or an E&M service that is for a problem separate from the hyaluronate injection. Office notes that justify adding the -25 modifier should be submitted with the claim.


  4. #4
    Thank you guys for all the info!
    Most helpful

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