# can e/m be billed on this as well with the injection??



## trose45116 (Jan 22, 2016)

E/M can be so confusing. I came from just coding surgeries and trying to understand E/M is so confusing.  I know the modifier 25 will be applied but since they are going to get her into pt and reviewed the MRI would this be enough to bill the OV??    Anyone have any examples of when an office visit can be billed with the minor procedure??


Right shoulder.  

 HPI: 
   Appointment type:  
       Established patient - Established problem Patient returns for her right shoulder. She denies any other complaints She continues to be symptomatically. She did obtain an MRI. She comes in today to review the results.  

 ROS:  
   Unchanged from 12/9/2015. 

 Surgical History: hysterectomy, rt ankle, lt knee .  

 Family History:  
arthritis, diabetes, stroke. 

 Social History:  
   tobacco- no
alcohol- no
single. 

 Medications: Taking Medrol (Pak) 4 MG Tablet as directed as directed 

 Allergies: N.K.D.A. 


Objective:

 Vitals: Wt 130 lbs, BMI 21.63 Index, Ht 65 in. 

 Examination: 
   General Examination: 
       GENERAL APPEARANCE: in no acute distress, well developed, well nourished. 
       EXTREMITIES: Exam of cervical spine, No tenderness to palpation of spinous processes. Normal ROM of cervical spine. No trapezial muscle spasm noted.Examination of right shoulder. No skin abnormalities. No masses. No obvious muscle atrophy noted in suprascapular fossae. No scapular winging noted. No specific periscapular tenderness to palpation. No AC joint tenderness noted. No SC joint tenderness elicited. Pain with palpation about the rotator cuff. No pain with palpation about the proximal biceps. Positve hawkins and neers test.Pain with Jobes testing. Weakness noted.Full active and passive shoulder ROM.Negative apprehesion, yergasons, speeds, belly press, lift off, bear hug, Pain with cross body adduction.Normal sensation to light touch throught entire left uppper extremity.Biceps, brachioradialis, triceps refelexes normal.Radial pulse 2+. Good capillary refill.5/5 motors with deltoid, biceps,triceps, BR, finger flexors, finger extensors, writst flexors, and wrist extensors.Examination of the opposite shoulder is within normal limits for ROM, motors, sensation, pulses and skin..      



Assessment:

 Assessment: 
1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic - M75.111 (Primary)   

Plan:

 1. Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic 
Notes: MRI of the right shoulder was reviewed. She does have evidence of a partial-thickness tear about the supraspinatus. This is articular based. Glenohumeral joint is well maintained subdeltoid bursitis. Subscapularis intact. Biceps intact. No labral tear.
At this point I did describe starting with a steroid injection. She was in agreement. She was taken to the procedure room. Under ultrasound guidance. 2 cc of Kenalog and 4 cc Marcaine was injected in the subacromial space. Patient tolerated this well. We will get her going in physical therapy. All questions were answered. If she does poorly. She would be a candidate for arthroscopic surgery.    


 Procedure Codes: 20611 INJECTION JOINT/BURSA/DRAIN W/US, J3301 Inj, triamcinolone acetonide 80mg 

 Follow Up: prn


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## hopepg (Jan 22, 2016)

This looks like the question you posted yesterday but for a patient with a hip condition. Look up what documentation is required in order to bill for an E/M code. The CPT manual has some information. Look up the 1997 or the 1995 guidelines on the internet. I have a paper that I've kept since going to school for coding that I reference every time. E/M was tough for me at first but once you get all the tools it all makes sense. Find a tool that makes sense to you & it will all come together!  

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

http://www.emuniversity.com/

http://e-medtools.com/Medicare_Coding_Tool.html

http://www.scribd.com/doc/7607086/E...d-Coding-Worksheet-E-M-Audit-Worksheet#scribd


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## trose45116 (Jan 22, 2016)

thanks for your response but I don't need to know how to figure out the level. I am just asking when is it appropriate to bill the ov with a procedure.  What do you look for when to determine that you can add the 25 modifier.   

in this case the pt came in and the MRI was reviewed and they are sending her to PT. If this doesn't work then she will likely have surgery.  Does this go above an beyond to be able to bill for the ov as well?




hopepg said:


> This looks like the question you posted yesterday but for a patient with a hip condition. Look up what documentation is required in order to bill for an E/M code. The CPT manual has some information. Look up the 1997 or the 1995 guidelines on the internet. I have a paper that I've kept since going to school for coding that I reference every time. E/M was tough for me at first but once you get all the tools it all makes sense. Find a tool that makes sense to you & it will all come together!
> 
> https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
> 
> ...


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## hopepg (Jan 22, 2016)

Oh I see, I misunderstood. Woops!

In my opinion based on training, understanding the E/M guidelines & experience:

"I am just asking when is it appropriate to bill the ov with a procedure. "

No matter what ends up being done on the same DOS, If the provider's documentation supports an E/M to be billed - then it should be included. 

"What do you look for when to determine that you can add the 25 modifier. "

Once you have determined from the documentation if it supports an E/M to be billed, the modifier 25 should just be appended to the E/M.


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## LoriCox (Jan 25, 2016)

*Intent*

Many times it depends on the intent of the visit. Was the patient scheduled to come in today for her injection - did the provider already know she needed one? If so, then there is probably no separately identifiable reason for an E&M. The work of the E&M is included in the injection code RVU's. However, if the patient came in for a recheck, and as a result of his findings today decides to give her an injection, then you may have just cause for billing an E&M. It is a very tricky area and some payers may not agree with that reasoning, however, I would bill and E&M in your example unless it was understood that the patient was just coming in today for an injection.


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## pscott (Jan 27, 2016)

If the Dr says they are evaluating the condition, I let them keep the E&M. If pt came in for procedure,
you can't charge for the E&M, unless other conditions were addressed.


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## trose45116 (Jan 28, 2016)

*only the injection to be billed out??*

I don't see anything coming out to be able to bill the E/M with the injection. any thoughts?? I am still trying to understand and learn the E/M. 


1. Right knee pain.  

 HPI: 
   Appointment type:  
       Established patient - Established problem Patient returns for his right knee. We last aspirated his calf in early December this helped him significantly. He is interested in possibly injecting his knee. He denies any other complaint.  

 ROS:  
   no change from 12-09-15. 

 Medical History: Diabetes, heart attack, hepatitis.  

 Surgical History: heart stents .  

 Family History:  No Family History documented. 

 Social History:  
   tobacco- no
alcohol- no
married. 

 Medications: Taking Aspirin , Taking Lisinopril , Medication List reviewed and reconciled with the patient 

 Allergies: N.K.D.A. 


Objective:

 Vitals: Wt 170 lbs, BMI 27.44 Index, Ht 5 ft 6 in. 

 Physical Examination:  
    Examination of the right knee shows no evidence of skin abnormality. He does have swelling on the patellofemoral Crepitus. Pain with palpation medial femoral condyle. No lateral sided tenderness. Relatively full knee range of motion. Knees ligamentously stable. Normal motor sensation pulses and skin examination distally. 


Assessment:

 Assessment: 
1. Arthritis of right knee - M19.90 (Primary)   

Plan:

 1. Arthritis of right knee 
Notes: Patient was taken to the procedure room. Under ultrasound guidance, 2 cc of Kenalog and 4 cc Marcaine was injected into the right knee. Patient tolerated this well. All questions were answered.    


 Procedure Codes: J3301 Inj, triamcinolone acetonide 80mg, 20611 INJECTION JOINT/BURSA/DRAIN W/US 

 Follow Up: prn


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