Neurology & Pain Management 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 both the E/M service and the carpal tunnel injection?

Answer: This is a good example of when a provider performs an E/M service that was "above and beyond" the usual pre- and postprocedure care associated with the carpal tunnel injection. The E/M service was performed for the patient's new complaint of right knee pain and you should consider it separately identifiable.

He can bill for the separately identifiable service as well as the significant E/M service to check the patient's problem with her right knee. Report, 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).

Remember: 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. 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.

Example: If the pain management provider made the decision to perform a carpal tunnel injection at a previous visit, and only 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 postprocedure care typically associated with that procedure.

According to the AMA's CPT Assistant, "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." Chapter 1 of the Medicare NCCI Manual states, "Since minor surgical procedures and XXX procedures include pre-procedure, intraprocedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient."