Orthopedic Coding Alert

A Medicare patient visits an orthopedic surgeons office for preoperative care that requires an injection. The service or procedure the patient requires is identified by a CPT code.

Coding is straightforward. For example, the CPT code 20610 (injection, major joint or bursa) or 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst) is reported along with the HCPCS J code to indicate the drug administered.

But the situation changes when the patient identifies a new symptom during the visit and the symptom requires retaking the history and an exam. Evaluation and management (E/M) services are necessary. Can the physician bill for the office visit requiring E/M services and for
the injection?

The short answer is yes. The longer answer is, In most cases, but be careful.

Many Payers Want Separate Diagnoses

Carol Ethridge, CPC, a coding and reimbursement specialist and the president of the Birmingham South chapter of the American Association of Professional Coders (AAPC), explains: An office visit with a separate identifiable diagnosis, and with a modifier 25 attached to the visit, may be billed [in addition to] the joint injection.

Technically, the 1999 CPT does not require separate diagnoses (cf. below, Clarifications). But they help to simplify the interaction with payers.

That is because a stumbling point when billing for E/M services and injections during an office visit is the distinctiveness of the symptoms. A new symptom (beyond the usual preservice and postservice care associated with the procedure performed, according the 1999 CPT) is a must. And the easiest way to support such a symptom is with a new diagnosis code.

Some scenarios are relatively clear-cut. A patient visiting the physician for a knee injection complains of shoulder pain. When the physician responds to the complaint by performing range-of-motion tests on the shoulder, the -25 modifier (significant, separately identifiable E/M service by the same physician on the day of a procedure) can be used.

Multiple Symptoms, One Diagnosis

Payer response becomes less predictable if the patient complains of a new symptom, such as a different kind of problem (e.g. weakness instead of pain) in the knee that is getting the injection. Will the criteria required for use of the -25 modifier be met?

The -25 modifier should apply, even if the diagnosis is the same, says Brett Baker, a regulatory affairs associate and third-party payment specialist at the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Washington, DC. Baker looked closely at the revised E/M services guidelines in the 1999 CPT, and wrote about them for members of ACP-ASIM.

He points out that a paragraph was added to the 1999 CPT, which reads in part: The E/M service may be caused or prompted by symptoms or conditions for which the procedure or service was provided. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

Although this new paragraph in the CPT should make it easier to get payers to recognize E/M services that are required in addition to a scheduled injection, the ultimate decision on interpretation rests with the payer. Baker says that his experience with Medicare payers is limited, but that ACP-ASIM members have been having good results with commercial payers.

In some situations, the path to reimbursement is much clearer. For example, when a new patient making a first visit to a physician receives E/M services and the services culminate in an injection, the office visit and the injection are billable. Susan Callaway-Stradley, CPC, CCSP-P, an independent coding consultant who was recently named the AAPC coder of the year, gave a scenario to illustrate this case in the April 1999 Orthopedic Coding Alert (page 28).

Note: The -25 modifier cannot be used when the E/M services result from a decision to perform surgery. Modifier -57 applies.

The Finer Points: Include J codes -LT, -RT and -50 modifiers

Although coding consultant Ethridge believes most coders understand the use of the -25 modifier for E/M services with an injection, she is concerned that many people forget to charge for the drug used in the injection. And she emphasizes that coders should use the correct J code to designate the drug used.

Beyond that, precise, front-side coding protects services from rebundling. If the injection is given on just one side of the body, use the appropriate modifier, -LT (left side) or -RT (right side). If the injection is bilateral, use modifier -50 (bilateral procedure).

Medicare specifies that the -50 modifier simply be added to the appropriate CPT code. For example, 20610-50 (injection major joint or bursa, bilateral)

Note: Some commercial carriers request a different format for the -50 modifier. Check with your carrier.

A bilateral injection is reimbursed at 150 percent
of the allowance for a unilateral procedure.

Finding Those ICD-9 Codes Covered for Injections

An OCA reader recently asked about finding a comprehensive list of ICD-9 codes that are covered for injection procedures 20610 and 20550. Ethridge recommends going to the carrier to get a selection of codes.

Ethridge notes that Blue Cross/Blue Shield of Alabama offers a database for coders at its Web site (http://bcbsal.org) and she suggests other coders might find the same sort of information available to them locally, through their carriers. Your carrier also will supply a list of up-to-date drug codes, which is prepared annually to keep pace with the addition of new drugs.