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Staged injections vs. e/m code

  1. #1
    Springfield, Mo
    Default Staged injections vs. e/m code
    Medical Coding Books
    Could I get some opinions on this please? When a patient returns for a subsequent or staged injection we only assign an e/m code to the visit if there is some new problem, or a new treatment or plan for the established problem. One of our doctors wants to charge an OV for return visits when the ONLY thing different about the documentation of this visit is this:

    If the pain returns in the future, Physical Therapy and custom-made orthoses will be arranged. The patient indicates understanding of these issues and agrees with the plan.

    I don't feel that we can take credit, or charge for something that may or may not happen in the future. Wouldn't this be improper use of modifier 25? Any thoughts? Thanks.
    solocoder CPC

  2. #2
    I agree with you. This is more of a agreement plan for future issues and that is all. You know the saying
    "if it's not documented than its not done". In this case it has not been done therefore sorry doc not happening. That's my opinion, good luck.

  3. #3
    You can only bill the Adminstration for injections and the injections. If he is wanting you to charge an office visit, I would say that falls on the fraud line. Only if the doctor sees the patient and there is documention for that visit can you charge. I agree with the previous post, the doctor is out of luck. If he were to get an audit, you would also be held responsible for the charges.

  4. #4
    I would not charge for E/M in this case. Inj already includes an assessment so you do not need an additional code for this unless something new comes up.

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