Eli's Rehab Report

Question: Ive been told that if a trigger point injection (CPT 20550 ) and x-ray of the spine (72010-72120) are performed during the same visit, an outpatient evaluation and management (E/M) code (99201-99215) has to be charged. But if the x-ray and the injection are for the same complaint and the same diagnosis, will the documentation support the office visit and injection charge?

Montana Subscriber

Answer: If the appointment was made for the injection and no E/M service other than that related to the injection was performed, only the injection and drugs used should be billed. An x-ray is an ancillary service, which may be performed independently of any other service; therefore an E/M service is not billed in addition. But the ordering of the x-ray must be noted in the patients chart.

Your coding department probably reasons that because the physician ordered the x-ray based on the patients symptoms or complaints, this is part of the decision-making of the E/M codes, and therefore separate from the injection fee. But it does not fulfill all the criteria required for using an E/M code.

You are correct in hesitating to bill an office visit in every instance. If there is enough documentation to demonstrate that there was a significant, separately identifiable E/M service, 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 service. Dont use the modifier (or the E/M code) if you dont feel the documentation supports the separate service. The physician's documentation should also justify the medical necessity of the x-ray.


- Advice for Reader Questions was provided by Neil A. Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pennsylvania Medical Center at Shadyside in Pittsburgh; and Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.