Eli's Rehab Report

To keep up with the new edition of the Correct Coding Initiative (CCI), which takes effect on Oct. 1, your practice will need to pay special attention to your injection coding.

CCI 8.3 bundles procedures such as 20550-20553, 20600-20605, 64400-64430 and 64550-64771 into other, more complex services. For instance, the trigger point injection codes (20552-20553) are now bundled into many of the nerve block codes (64400-64530).

Although these edits are new to CCI, many carriers have been bundling injections into these procedures for years, and version 8.3 merely makes the trend official. However, this does not necessarily mean that your practice must write off the cost of every injection performed with other procedures, says Gregory J. Mulford, MD, medical director at Atlantic Rehabilitation Services and chairman of Rehabilitation Medicine at Morristown Memorial Hospital in N.J.

"The CCI Edits do not preclude use of the modifiers if you perform and document a separately identifiable service on the same day as an injection," Mulford says. In particular, he points to modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for injections performed with E/M services, and modifier -59 (Distinct procedural service) for injections performed with other types of procedures.

For instance, says Rebecca Savino, office manager at Rehab Health, a solo practice in Waterbury, Conn., "We usually perform E/M services with our injections, and we bill the injection, the E/M with modifier -25 appended, and the J code for the injectable drug." Savino cautions that the E/M service must be a significant additional service, and not simply pre- and postinjection care.

Lift Injection From Documentation

How can you tell if your E/M service or other service is significant and separately identifiable from the injection?

According to Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopaedic Associates in New Brunswick, N.J., most payers will readily pay for both a new patient office visit and an injection, but reimbursement becomes trickier when an established patient is involved.

Stout advises practices to lift the injection procedure out of the rest of the documentation. "If your notes from the E/M service alone indicate a significant and separately identifiable E/M service, you can submit both codes on your claim."

Stout reminds coders to make sure the E/M notes identify the three key elements of history, physical exam and medical decision-making.

Common instances when this is allowable include established patients who present for prescheduled injections but also report unrelated problems (such as ankle bursitis, 726.79). In this case, the physiatrist might perform the scheduled trigger point injection for neck pain (723.1), a separate E/M service for the bursitis, and a bursa injection to the ankle (20605).

The claim would read as follows:

20552 (723.1)
20605-59 (726.79)
99213-25 (726.79)

Stout advises practices to record the injection documentation separately from the E/M documentation, with a complete procedure note for both services. She offers the following as a complete note when performing a tendon sheath injection (20550):

"After sterile Betadine preparation of the injection site and application of topical anesthetic, the symptomatic tendon was identified, and a 22-gauge needle is inserted into the tendon sheath. A solution of Xylocaine and Celestone is injected. The needle is withdrawn, and the injection site is cleansed and bandaged. The patient tolerated the procedure well and after a period of monitoring was discharged with instructions for post-injection care."

Other notable CCI changes include the bundling of many strapping codes (29520-29580) into most injection codes, and inclusion of the health and behavior assessment/intervention codes (96150-96155) with the physical and occupational therapy evaluation and reevaluation codes (97001-97004).