Eli's Rehab Report

Question: Can we charge an E/M service on the same day as an epidural block?

North Carolina Subscriber
 
Answer: Yes, you can report an E/M service on the same date - if the service is significant and separately identifiable from the epidural block.
 
For example, a patient presents for an injection but also complains of symptoms resembling carpal tunnel syndrome (354.0). The physiatrist performs the injection and spends 15 minutes examining the patient because of the new complaint.
 
For this visit, code the injection (e.g., 62311, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) and the E/M service (e.g., 9921x, Office or other outpatient visit for the evaluation and management of an established patient...) with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M service code.
 
Appending modifier -25 to the E/M code demonstrates that the physiatrist examined the patient for the new complaint and that the service was significant and separately identifiable from the epidural block.
 
Remember: You must document the separate nature of the E/M service in the medical record.