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 exam is considered to be a routine preoperative service and a visit should not be billed in addition to the procedure. Only the injection code (20610) and the J code for the cortisone should be billed to Medicare.

How is Modifier -25 Related to Starred Procedures?

There are occasions, acknowledges Georgia Medicare, when a practice can appropriately bill for an office visit along with an injection code by appending modifier -25. The 1999 CPT manual revised this modifier, explaining that different diagnoses are not required for reporting of the E/M services on the same date as a procedure.

However, that doesnt mean payers are following it.

Even though CPT came out with a revised definition of modifier -25, it was obvious they did not get payer input before they revised it. The insurance companies, Medicare included, are looking at different diagnoses with that modifier on the same day as a procedure. That is why CPT defines modifier -25 as separately identifiable, says Terry Fletcher, CPC, CCS-P, a McVey Associates Consultant in Laguna Beach, CA.

Tip: Separately identifiable also means that your documentation demonstrates something significant beyond the procedure having been performed and which can be identified separately from the procedure. To be on the safe side, ask yourself, If I remove everything in my documentation relating to this procedure, do I still have enough evidence to support a significant level of service?

For example, Georgia Medicare gave Burnett this second scenario to explain when modifier -25 should be billed with an injection code. Note the different diagnoses of shoulder pain (719.41) and knee pain (719.46).

The patient complains of pain in the shoulder. The physician examines the patient, does range of motion tests, and determines that a joint injection is needed. The physician injects the shoulder. The patient then complains of pain in his knee. The physician then examines the knee, does range-of-motion tests, and determines the knee does not need an injection. An E/M visit can be billed in addition to the injection into the shoulder and the J-code for the medication injected. Modifier -25 must be added to the E/M service and billed with a diagnosis of knee pain. The injection code should be billed with a diagnosis of shoulder pain.

When Can an Office Visit Be Billed with an Injection Code?

Our sources offer these guidelines:

1. If this is the patients first visit for joint pain, generally an office visit is billable in addition to the joint injection. The most likely scenario [for billing an E/M code in addition to an injection code] is that it would be either on the first visit for a new patient, or for an established patient, one in which a notable change in symptoms required retake of the history and exam, says Susan Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Company, LLP, headquartered in Greenville, SC.

For example, after evaluating a new patient with complaints of joint pain, stiffness and shooting pain down both legs, the orthopedist decides to inject 75 mg of cortisone into each hip joint the dame day. In that case, you would use diagnosis code 71945 and CPT codes as follows:

20610 (major joint or bursa)

append modifier -50 (bilateral) to joint injection code

9920X (office or other outpatient services, new patient)

append modifier -25 (significant, separately identifiable E/M service) to E/M service

J0810 (injection, cortisone, up to 50 mg) x 3

Tip: Ask your payers if they want the surgical code for injections used once with the modifier (code plus modifier -50) or used twice (code alone and code plus modifier -50). For example, in Massachusetts, Medicare and Blue Cross require the injection code and modifier to be listed on one line, e.g., 20610-50. But other commercial carriers in the state want both injections itemized on two lines such as:

Line 1: 20610

Line 2: 20610-50

2. If the patient returns to get a subsequent scheduled injection, generally that second office visit is not billable. For example, if an orthopedist gives a scheduled injection of 50 mg cortisone each into the patients left and right hips, append modifier -50 to code 20610. Procedures billed with modifier -50 are reimbursed at 150 percent of the allowance for the unilateral procedure. (You wont get full reimbursement for the second procedure. The reduction for modifier -50 is similar to modifier -51 in that it designates overlapping of the surgical package.)

Remember to bill for the drug itself by using J0810 x 2. (If your carrier does not accept HCPCS II codes use 99070.)

Its easier to get paid [for an E/M code and a joint injection] the first time a new or even established patient appears with joint pain, says Stradley. But if the orthopedist says, If its still hurting in three weeks, well try another one, then that subsequent office visit isnt billable, although, of course, you can still bill for the injection.