Outpatient Facility Coding Alert

Question: An established patient with a history of left knee injuries reported to our urgent care center complaining of pain in his left knee; he described his pain as 6 on a scale of 10. The provider performed a problem-focused history and examination, then prescribed ibuprofen, rest, and ice. Four days later, the same patient returned with more severe left knee pain (9 on a scale of 10). He said that he twisted the knee when he tripped over his dog. For the second encounter, the physician performed a level-four E/M and a single trigger point injection (TPI) to relieve the pain. Can I report an E/M code for each encounter?

Michigan Subscriber

Answer: Since there was a change in the patient’s injury that required more physician expertise, you would be able to report an E/M code for the first encounter. For the second encounter, you could report an injection code along with an E/M code for the second encounter. You’ll need a modifier for the second visit, however.

Do this: Report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making) for the patient’s first visit.

For the second encounter, report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the trigger point injection, and 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity) for the E/M. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to show that the E/M was a separate service from the TPI.

Reasoning: The patient had a significant change in knee pain that the physician had to examine a second time to see if the patient had incurred further injury. The change in pain could even mean that the physician will have to change treatment options for the patient.

If there is enough difference in the patient’s condition to merit more treatment (such as an injection to manage pain), you can report an E/M code with modifier 25 in addition to the injection for the second encounter. If there’s no medical necessity for a full history and examination, however, you shouldn’t bill another E/M service along with the injection on the second encounter.

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