Anesthesia Coding Alert

Question: Our pain management specialist saw a patient with carpal tunnel syndrome for a planned injection. At the same encounter, he also evaluated the patient for new pain she was experiencing in her right knee. Can we report the E/M service separately from the carpal tunnel injection?

Indiana Subscriber

Answer: The provider performed an E/M service for the patient's new complaint of knee pain. This E/M service was "above and beyond" the usual pre- and post-procedure care associated with the carpal tunnel injection, and you should consider it separately identifiable.

He can bill for a significant, separately identifiable E/M service to check the patient's problem with her right knee -- for example, 99213 (Office or other outpatient visit for the E/M of an established patient, which requires at least two of these three key components: an expanded problem-focused history, an expanded problem-focused examination, medical decision-making of low complexity.).

Don't forget: You'll need to let the payer know that your provider is not "unbundling" the injection procedure by appending modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the appropriate E/M code. Good idea: Link the E/M code to the diagnosis code 719.46 (Pain in joint; lower leg) to indicate that the E/M service was due to the patient's new complaint of right knee pain.

For example: If the pain management provider made the decision to perform a carpal tunnel injection at a previous visit, and performs a brief exam of the patient's wrist, explains the procedure and obtains informed consent for the injection during the current visit, you should not report the pre-procedure evaluation as a separate, billable E/M service.

Good info: Reimbursement for pain management procedures such as carpal tunnel injection includes the pre- and post-procedure care typically associated with that procedure.

The AMA's CPT Assistant says that "CPT codes for procedures include certain procedure-specific evaluation services that are necessary prior to performing the procedure itself. Generally, these services are limited to assessing the site or condition of the problem area, explaining steps in the procedure, and obtaining informed consent." CMS guidelines state that E/M services such as established patient visits should not be billed on the same day as a previously scheduled procedure.