EM Coding Alert

Question: If a doctor injects a high-end injectable such as Synvisc, Hyalgan, Orthovisc or Euflexxa, is it alright to charge an E/M with modifier 25? Our practice is that we do not bill an E/M with a high-end injectable if the physician discussed the injections with a patient up to as long as three months prior to the injection.

West Virginia Subscriber

Answer: You cannot bill an E/M service, with or without modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service), in this situation. 

Since the injectable has already been discussed with the patient three months prior to the injection, and no further unrelated evaluation was done during the visit for the injection, you cannot bill an E/M service with the injection code.