Orthopedic Coding Alert

Cortisone joint injections are a mainstay for orthopedic practices. Yet many are inappropriately billing injection codes (20550-20610) with office visits, which could put the practice at risk for fraudulent billing, experts warn.

For example, if the injection was previously scheduled and planned, an Evaluation and Management (E/M) code cannot be billed in addition, unless a significant separately identifiable service was also performed.

To correctly bill joint injection codes you first need a sound understanding of starred procedures as described in the CPTs Guidelines for Surgical Procedures. Next, youll need to review the recent changes regarding modifier -25 (significant, separately identifiable E/M service by same physician on same day of procedure or other service). Finally, youll need to check with your local Medicare carrier as well as your top five payers to find out their policies on billing E/M codes along with injection codes.

What is a Starred Procedure?

Starred procedures are minor surgical procedures requiring a varying amount of preoperative and/or postoperative services. They are identified in the CPT manual with an asterisk (*) after the code number. Because such procedures are considered technically surgical procedures, it should follow that you ought to be able to bill for an office visit as well. However, most insurance companies dont recognize that technicality.

Their rationale is that starred procedures, by
definition, dont have set global surgery packages, which include all preoperative, intraoperative and postoperative services associated with the procedure. Therefore, they believe the carriers can determine what is included in the global package for an injection, and they deem the office visit is included. Hence, in their view, the office visit cannot be billed separately. (The global surgery fee payment is made for the whole package, not for individual items within the package.)

Payers, who have varying definitions about what is to be included in the surgery package, establish a predefined number of days before and after the surgery that are considered part of the surgical procedure.

Note: Because the relative value units (RVUs) have been calculated into the injection codes to include the pre-op exam (or office visit exam), if youre billing the starred procedure code plus the E/M code, youre unbundling. For example, with established patients, the CPT manual states that when providing follow-up care and a major service, a service visit is not usually added.

Medicare Says Dont Bill Office Visit When...

Coder Teresa Burnett asked Georgia Medicare to clarify when an office visit should or should not be billed in conjunction with an injection code.

The carrier offered this scenario to explain when a visit should not be billed: The patient complains of shoulder pain. The physician examines the shoulder, performs range-of-motion tests, and determines that a joint injection should be done on the shoulder. The [...]