Internal Medicine Coding Alert

Question: Our internist recently diagnosed a patient with symptoms of nausea and headache with migraine. He then proceeded to inject the patient with two intramuscular injections. Our doctor is asking me to report 99213-25, 96372x2 with modifier 59 along with the appropriate J codes. I am of the contention that a separate E/M cannot be reported. Who is right?

Texas Subscriber

Answer: You can bill both the E/M with modifier -25 and the therapeutic injection codes if the documentation supports that the E/M service was significant and separately identifiable from the therapeutic injections. If billing for any significant, separately identifiable E/M with modifier -25 attached, make sure that the documentation shows that the appropriate number of key components (i.e. history, exam, and medical decision making) were done (for example, two of three for an established patient).Some providers will even go so far as to have separate documentation for the E/M service and the procedure provided at the same encounter. Without sufficient documentation, you cannot bill a separate E/M.

As per guidelines, “an E/M service for an established visit requires two of three key components: history, examination, and decision-making. Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete and will result in a denial, with or without the Modifier 25.”