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 [...]