Orthopedic Coding Alert

Separate diagnoses aren't necessary, but they help

If your carrier has suddenly started denying E/M services when you perform joint injections at the same visit, don't give up hope. Although Medicare payers have started issuing denials for these services, you can still collect if you know the right modifier and assign the appropriate diagnosis codes.
 
Orthopedic coders report that carriers have recently started refusing to pay for E/M visits on the same day as joint injections, even when the doctor performs separately identifiable work.
 
Example: A patient complaining of elbow pain (719.42, Pain in joint; elbow) visits the physician. The orthopedist diagnoses the patient's pain as arthritis (such as 715.12, Osteoarthrosis, localized, primary; elbow) and administers a joint injection (20605, Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa).
 
The physician should be able to bill for both the E/M and the injection, says Ryan Price, CPC, CCS-P, manager of coding operations at Aviacode, a coding outsourcing company in Salt Lake City.

Separate Diagnoses Aren't Necessary

Problem: The only way that many carriers will pay for the separate E/M without a hassle is by using a different diagnosis. When this is an option, you should report both ICD-9 codes, because they better describe the reason the physician performed two services.
 
Caution: In our example above, you couldn't simply list "elbow pain" for the E/M and then the more definitive diagnosis of arthritis for the injection, because this goes against ICD-9 reporting guidelines.
 
These guidelines state, "Codes that describes symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the physician," but "signs and symptoms that are integral to the disease process should not be assigned as additional codes." Therefore, because the patient's condition has been diagnosed as arthritis, you should no longer report elbow pain.
 
But even if you don't have separate diagnosis codes, as long as you perform a separately identifiable, medically necessary E/M service, you should still report both the E/M and the injection.

Append -25 to E/M Code

Although reporting two separate diagnoses - one for the injection and a different one for the E/M visit - will help cinch your reimbursement, separate diagnoses aren't required by CMS standards. As long as you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, you can report both services with the same diagnosis code when necessary.
 
Example: A new patient presents and complains of knee pain. The orthopedic surgeon performs a level-three new patient evaluation and administers a joint injection (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). He asks the patient to return in two weeks for a follow-up visit. 
 
You should report the appropriate new patient E/M code (99201-99205) with modifier -25 appended, along with 20610 and the applicable HCPCS code (such as J0702, Celestone Soluspan). Report 719.46 (Pain in joint; lower leg) as the diagnosis code for both services.

Don't Bill E/M for Scheduled Injection

If the patient is scheduled to come in for an injection in advance and you don't perform a separate exam with the injection, you shouldn't bill for an E/M visit in addition to the injection charge. But if the orthopedist sees a new problem, then he can legitimately perform an E/M service and bill for it.
 
"If the patient comes in and has an E/M, and the doctor says, 'Try anti-inflammatories for two weeks, and then come back for a joint injection if they don't work,' " then you shouldn't bill for another E/M visit with that previously scheduled injection two weeks later, says Kim Johnson, director of medical billing services for TPi Billing Solutions in Tulsa, Okla.

Separate Injection, E/M Documentation

Strategy: One good rule of thumb is to look at the documentation for the E/M claim and remove all dictation related to the injection. If the E/M is at least a level-two without any reference to the injection, then you should bill it separately.