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e/m and multiple injections.

  1. #1
    Default e/m and multiple injections.
    Medical Coding Books
    I need some help. I have an encounter with an est pt office visit for follow up bilateral shoulder tendonitis. Patient also has a new complaint of left knee pain. The doctor discusses treatment option for all three problems. The patient agrees to have injections done during this visit. So I would bill an office visit with modifier 25, 20610-lt for the left knee, and now for my dilemma, for the shoulder injections would I code 20610-59-rt and 20610-59-51-lt? Our system does not recognize modifer 50 so I have to use rt and lt. If this is wrong please let me know how this would be coded.

    Thanks

    Coderforlife

  2. #2
    Thumbs up joint injection with E/M
    As per your Quote, need to supportive evidence or work for other problems with Joint injection procedure to justify the separate level of e/m code then we need to code level of service with mod-25 if we unable to prove separate work of physician then we need to code and bill CPT code 20610-RT and 20610-LT without any numeric Modifiers i.e. 59 or 51 with procedure codes.

    Quote Originally Posted by coderforlife View Post
    I need some help. I have an encounter with an est pt office visit for follow up bilateral shoulder tendonitis. Patient also has a new complaint of left knee pain. The doctor discusses treatment option for all three problems. The patient agrees to have injections done during this visit. So I would bill an office visit with modifier 25, 20610-lt for the left knee, and now for my dilemma, for the shoulder injections would I code 20610-59-rt and 20610-59-51-lt? Our system does not recognize modifer 50 so I have to use rt and lt. If this is wrong please let me know how this would be coded.

    Thanks

    Coderforlife

  3. Default
    Hi,
    E/M with 25 modifier required because more than one problem addressed, as one problem should be pertinent;
    If your procedure note reads injection for tendinitis - Cpt 20551-50,59 can be considered for bilateral shoulder;
    and 20610 - LT/RT can be considered for knee joint injection and or aspiration;
    (Reimbursement for arthrocentesis, aspiration and/or injection of major joint or bursa CPT 20610, will not exceed four (4) services per site within a thirty (30) day period.)

    Regards,
    LMohan

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