# E&M with cortisone injection



## debatortho (Apr 28, 2011)

We are an ortho office and have been very careful about billing an office call with an injection for an established patient.  If it is a new problem, we will bill the office call of course, but we have a number of patient's that just come in routinely for injection and we don't bill and E&M for those.  My question is - when a patient comes back after an MRI scan which is reviewed with the patient and the decision is made to do a cortisone injection - can I bill an office call?   Thanks!


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## btadlock1 (Apr 28, 2011)

debatortho said:


> We are an ortho office and have been very careful about billing an office call with an injection for an established patient.  If it is a new problem, we will bill the office call of course, but we have a number of patient's that just come in routinely for injection and we don't bill and E&M for those.  My question is - when a patient comes back after an MRI scan which is reviewed with the patient and the decision is made to do a cortisone injection - can I bill an office call?   Thanks!



As long as you've got the components documented, you should be able to bill an E/M - the key is, that there was a _medical decision _made at the encounter. You still have to have a chief complaint, at least one HPI, and a physical exam *documented*, in addition to the MDM to be able to bill it. Medical necessity is definitely there, though, so you're safe.

You guys are correct in not billing an E/M when the patient's injections are part of a previously established regimen, but you can bill for patients who had already had their problem established, as long as there was a significant change to their treatment plan - trying out an iinjection (even just once), is enough to count as a significant change.


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## debatortho (Apr 28, 2011)

Perfect.  I will see if I can get them to do an exam in that instance and then we can bill.    Thanks!


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## btadlock1 (Apr 29, 2011)

debatortho said:


> Perfect.  I will see if I can get them to do an exam in that instance and then we can bill.    Thanks!



Glad I could help!


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