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Thread: Orthopedics Coding

  1. #1

    Default Orthopedics Coding

    AAPC: Back to School
    Hello everyone,
    I have a few questions for you concerning billing. My first question is I have a few insurances (Aetna, Cigna, GHP, and Medicare) that are saying that our office visit with a -25 mod is bundled with the injection or the x-ray. We own our machine and we also read them. They are saying that the injection is bundled with the office visit. They pay on some and not on others. Any input would be appreciated, on how I can get these paid. Maybe we are coding them wrong etc. My second question is how I get a print out of what is considered for each insurance company and what the average pay put is on codes. I have a Medicare 2012 fee schedule that we go by for now. Thank you all in advance for helping me out with this.
    Krystal Prass CPC-A
    Krystal Prass, CPC-A

  2. #2
    Join Date
    Apr 2007
    Manhattan, NY


    If your doctors have participating provider Ids for each carrier, they will often allow you to download a copy of their fee schedule, type in a specific CPT code for a fee on their website, or your provider representative will get the fees you need for the CPTs you want. Sometimes this is time consuming, but will be worth the effort.

    My understanding for injections is that as long as the E&M is significantly separate, modifier 25 is appropriate, so you will need to appeal on that basis. Also, you should be able to bill the E&M, administration for the drug, and the "J" code as long as you supply all the required detail. There are general rules for this, but you will have to contact the carrier to find out what they are looking for. Your insurance carrier Provider Representative is there to help, so do not be shy!

  3. #3


    The documentation would have to show that there was an examination and that in the course of the examination, it was determined that the injection would be the course
    of action. In other words, the patient did not specifically come in just to get the injection.
    It was not pre-determined.

  4. #4


    If patient is coming in for a sore shoulder-Bill the appropriate E and M with a 25 modifier and use sore shoulder as the dx code. For the injection code-code the appropriate code that the physician says- its the physicians final diagnosis as to what the patient has.

  5. #5


    Add a mod 59 to the injection.

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