Anesthesia Coding Alert

Question: Can I code an E/M visit along with an injection? The anesthesiologist discussed the possibility of performing pain management injections during a standard visit, and the patient agreed to have one that day. Should I include any modifiers with the claim?

Tennessee Subscriber

Answer: Yes, you can code for both an E/M visit and an injection administration on the same day, but report the procedure as a Type of Service "01" (medical care) instead of Type of Service "07" (anesthesia service). Be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to document that performing the injection during the standard visit was unusual but necessary.
 
Some carriers initially balk at reimbursing claims with modifier -25. If the carrier denies the claim, resubmit it with the physician's notes for review. Also remember that you can only bill an E/M visit with an injection if the E/M resulted in the decision to perform the injection or if the patient has an "Oh, by the way" type of problem the physician learns about during the visit. If the patient comes to the physician for the injection, the E/M visit is bundled with the procedure and cannot be separately coded.