Internal Medicine Coding Alert
Check for E/M on Non-Scheduled Procedures
Question: An established patient with osteoporosis reports to the internist with a new complaint of wrist pain. The internist performs an evaluation of the patient's complaint and diagnoses bursitis. The internist performs a wrist injection with 40 mg of Sano-Drol (Methylprednisolone). Can I report a separate E/M in this scenario? Arkansas Subscriber Answer: The patient's medical record should contain the following information in case the claim comes up for payer review: "Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient's medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim," according to the Medicare Claims Processing Manual. If it does then you can report an E/M. On the claim, you would report the following: • 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) for the arthrocentesis
• the appropriate level E/M code (99212-99215) based on the encounter notes
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code to show that the E/M and the injection were separate services
• 726.4 (Enthesopathy of wrist and carpus) appended to 20605 and the E/M code to represent the patient's bursitis
• 733.00 (Osteoporosis, unspecified) appended to 20605 and the E/M code to represent the patient's osteoporosis
• J1030 (Injection, methylprednisolone acetate, 40 mg) for the Sano-Drol supply.
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