Modifier Coding Alert

Question: A patient came into the office to see our orthopedist to receive a knee injection. The patient has had injections from this physician in the past. Can I use modifier 25 on this claim?

New York Subscriber

Answer: If you have sufficient history, exam, and medical decision making (HEM) to support billing a separately identifiable service, you can use 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) on this claim.

The E/M service should be separately identifiable from the injection. You’ll report the E/M service using the appropriate new patient code from the range 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or established patient code from the 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient…) range.

Keep in mind: All procedures include some level of E/M that result in HEM. The physician needs to clearly document that he performed more than the history, exam, and medical decision making included with every injection if you are using modifier 25. In other words, you should be able to “carve out” the service that was unrelated to the injection to get the level of service for the E/M code you will bill.

Example: An established patient with a documented diagnosis of knee arthritis presents two weeks after her prior visit for a scheduled knee injection. She states that she now also has pain in her shoulder. After an examination, the physician determines she has bursitis or tendonitis in the shoulder. The physician then administers the knee injection for the previously diagnosed arthritis. Because the bursitis/tendonitis is a new diagnosis, unrelated to the previous diagnosis of arthritis, modifier 25 is appropriate to use to seek separate payment for the E/M visit for the shoulder pain.

Bottom line: If you do not see “extra” history, exam, and medical decision making that support a separate service, you should only bill the injection code.