# New Injection Guidelines



## dwmt1 (Jan 3, 2013)

I work for a large Ortho practice and with the new Injection guidelines set forth by CMS in New York, there is a lot of questions.  I understand that if a patient comes in for an injection and there is no other issue addressed, then the injection is the only procedure to be billed.  One of the many questions asked of me is if you see a new patient and after exam you decide that an injection is necessary, the new guidelines are telling you to just bill the injection.  I am thinking you report the higher RVU regardless of services performed because you know they are bundled.  Please confirm and thanks in advance.


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## hewitt (Jan 3, 2013)

Which injection guidelines...? CMS has specific direction for various injections. Please clarify.


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## mitchellde (Jan 3, 2013)

dwmt1 said:


> I work for a large Ortho practice and with the new Injection guidelines set forth by CMS in New York, there is a lot of questions.  I understand that if a patient comes in for an injection and there is no other issue addressed, then the injection is the only procedure to be billed.  One of the many questions asked of me is if you see a new patient and after exam you decide that an injection is necessary, the new guidelines are telling you to just bill the injection.  I am thinking you report the higher RVU regardless of services performed because you know they are bundled.  Please confirm and thanks in advance.


This is not new, this has been this way for some time unless there is more that we are not seeing.  If the only thing addressed is the need for the injection, scheduled , unscheduled , new or established patient , you bill only the injection.  You do not need a separate diagnosis but you do need a significant examination.  The injection includes the exam necessary to give the injection.  So you need documentation that over, above, and beyond what is necessary to determine to give the injection.  Then you may bill the E&M with a 25 modifier and the injection.
Perhaps your local FI came out with some new guidelines to help clarify this issue.


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## dwmt1 (Jan 3, 2013)

Thank you, I ended up finding in the CCI manual the exact language where a new patient does not qualify for the 25 modifier.  Now they want to know if they should bill for the New patient visit or the injection.  I would say the more comprehensive code.  Any thoughts?


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## mitchellde (Jan 3, 2013)

Could you please share this from CCI?  as I know of nothing that states you cannot bill a new patient visit with a 25 modifier.


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## mitchellde (Jan 3, 2013)

The only statement I have found in CCI is this:
This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 thorugh 99285, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.

However this does not state that you cannot bill the new pt code and the injection, rather it states that you can bill them and it does not require the 25 modifier

Do you have something different than this.. This is dated 2013


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## mitchellde (Jan 3, 2013)

The only statement I have found in CCI is this:
This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 thorugh 99285, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.

However this does not state that you cannot bill the new pt code and the injection, rather it states that you can bill them and it does not require the 25 modifier

Do you have something different than this.. This is dated 2013


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## risnerclan (Jan 4, 2013)

We are having this same discussion in our office now.  We have an article from the Legislative & Regulatory Update volume 7, issue 12 dated December 2012 and it states as follows:

CCI clarifies E/M bundling policy

New language added to Chapters 1 and 4 of the manual makes it clear:  E/M services "on the same date of service as the minor surgical procedure are included in the payment for the procedure."

A code with a global period of zero days (000) or 10 days (010) in the physician fee schedule is defined as a minor surgical procedure, according to Medicare rules. 

That means that when the provider makes the decision during the course of the E/M visit to do the minor procedure (e.g., an injection), that visit is then "included in the payment for the minor surgical procedure and should not be reported separtely," the CCI policy manual now states.

Reference :  CCI Policy Manual

I have looked at those changes in the manual and it clearly states this and it also says that the fact that the patient is "new" to the provider is not sufficient alone to jusity reporting an E/M service on the same DOS as a minor surgical procedure.


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## risnerclan (Jan 4, 2013)

so our question is also, would you report the higher RVU regardless of the procedure performed.

Thanks for your help!


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## mitchellde (Jan 4, 2013)

I tried to find your reference but nothing would come up.  I cannot help but think it is being misinterpreted but it is hard to tell since you posted only a portion.  
From the most recent update 
Medicare Claims Processing Manual
Chapter 12 - Physicians/Nonphysician Practitioners
Table of Contents
(Rev. 2464, 05-04-12)

Same Physician on Date of Global Procedure
Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.
Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the
patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.
If the physician bills the service with the CPT modifier “-25,” carriers pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:
• When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;
• When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or
• When a carrier has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier “-25” compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the carrier may impose prepayment screens or documentation requirements for that provider or group. When a carrier has completed a review and determined that a high usage rate of modifier “-57,” the carrier must complete a case-by-case review of the records. Based upon this review, the carrier will educate providers regarding the appropriate use of modifier “-57.” If high usage rates continue, the carrier may impose prepayment screens or documentation requirements for that provider or group.
Carriers may not permit the use of CPT modifier “-25” to generate payment for mmultiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier.

So the answer is depending on the documentation you bill the E&M and the procedure or you bill the procedure only it all depends on the documentation.


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## risnerclan (Jan 7, 2013)

attached is an an article from Margie Vaught, this attachment was under another question that was posted on the forum about shoulders but also has the injection information on it as well.  i will be more then happy to email the other article i have if anyone would like.

http://margievaught.com/index.cfm?fu...=1&eventID=139


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## mitchellde (Jan 7, 2013)

This article says the same thing I have stated and as stated in the Medicare manual. It just says it differently.  She states that the decision to performe the surgery is included, I stated that the evaluation necessary to perform the procedure is included... same thing.  She states that this applies even if the patient is a new patient, I said same.  She says "However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. "
I stated that if the assessment is over above and beyond the assessment needed for the procedure then you may bill the E&M.  This is the same statement.
Many payers will auto deny an E&M with a porocedure even if the 25 modifier is attached as they are betting you will write it off or not have sufficient documentation to support the usage of the 25 modifier.
No you may not bill only the service with the higher RVU, you bill what the patient came in for/procedure performed.


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