Primary Care Coding Alert

The typical treatment for conditions like tendinitis, osteoarthritis, rheumatoid arthritis or other joint maladies includes joint injections (20600-20610). As straightforward as the injections seem, this service raises questions among many family practice coders. They often debate whether an evaluation and management (E/M) service may be charged in addition to the injection, and if the drug administered may also be reported. Plus, coders are often stumped about how to code multiple injections either to different joints or to the same joint on opposing sides of the body.

Not surprisingly, the answer to these questions depends on the situation. Coders may not report an E/M code, for instance, if the patient visits the office for the sole purpose of receiving the joint injection. Other patient visits, however, allow the E/M code to be assigned also. Likewise, some drugs may be reported with HCPCS Level II codes but others may not be.

Reporting E/M Services With Joint Injections

Whether an E/M code may be reported in addition to the joint injection depends on several factors. The most clear-cut of these are situations where E/M services are never reported with the injection code: on those rare occasions when the patient is seen only for a preplanned injection. Some patients may require a series of injections. Although the initial evaluation of the injury may justify both an E/M and injection code (see specific circumstances described below), followup treatments would be reported only with the injection code.

Beyond this circumstance, however, the issue becomes more complex and correct coding may depend on whether the E/M services are related to the reason the injection was given.

Both an E/M code and the joint injection code may be reported if a patient is seen for a condition or illness that is unrelated to the diagnosis that ultimately requires the injection, according to Randy Thompson, CPC, coding specialist with HMI, a consulting firm based in Nashville that specializes in Part A and Part B billing.

For instance, he says, a physician may see a 45-year-old woman suffering from an upper respiratory infection (URI). During the exam, the patient also mentions she has pain and stiffness in her left shoulder. The family physician diagnoses osteoarthritis (715.11) and gives an injection of cortisone (J0810) into the joint to reduce the inflammation. Because the woman presented with symptoms of an URI and there was no predetermined plan to provide an injection, coders would assign the appropriate level of outpatient E/M service (i.e., 99213, for an established patient) and 20610* (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g. shoulder, hip, knee joint, subacromial bursa).

Policies for Starred Procedures Complicate Coding

The issue becomes clouded when a patient is seen for symptoms that ultimately lead to a diagnosis indicating the medical necessity for an injection. Injection codes 20600*-20610* are starred procedures, which indicates the service includes only the injection. CPT says that pre- and post-procedural services including E/M services may be billed independently as long as the injection was not the sole reason of the patient visit.

Under CPT guidelines, therefore, both codes may be reported when a 35-year-old man who plays tennis is seen for elbow pain, diagnosed with enthesopathy (726.32, lateral epicondylitis) and treated with an injection (20605*, arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa). Because the patient was seen for pain and the need for an injection had not yet been determined, Thompson says, both an office visit code and the injection code may be reported.

Although coders would assign an outpatient E/M code for an established patient (99211-99215) in this instance, they would use 99025 (initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) for new patients. Rules governing CPT starred procedures note that this code should always be reported when a starred procedure is carried out at the time of an initial new patient visit and the starred procedure constitutes the major service at the visit.

Coders should also recognize, however, that Medicare and some private payers do not recognize CPT starred procedures. Therefore, payers may not consider related E/M services separately reportable. In these instances, family physicians would report and be paid for only the injection. Because payer policy differs, coders should check with individual payer medical directors to determine appropriate reporting procedures.

If the insurer allows both codes to be assigned, Thompson says, the E/M code would be appended with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

When reporting both an E/M and a joint injection code, it is wise for coders to make sure they link the appropriate diagnosis to each procedure code to minimize the chances of denial, Thompson adds. In the previous example of the patient with tennis elbow, for instance, coders would link the E/M service to the pain symptom (719.43, pain in joint, forearm) and the injection to the tennis elbow diagnosis (726.32).

Multiple Injections Also Challenge Coders

Modifiers and diagnosis codes are equally important when multiple joint injections are given to a patient on the same day, points out Laura Pettigrew, RHIA, CCSP, CPC, training and auditing coordinator for Methodist Medical Group, which provides coding services to 96 physicians in the Indianapolis area. It is understandable that insurers have questions when they see the same procedure reported twice, she says. Conscientious ICD-9 coding and use of the appropriate modifiers answer those questions and allow the claim to be processed smoothly.

A patient suffering from tendinitis, for instance, may need an injection in both a shoulder and a knee joint. Coders would assign injection code 20610 twice. This will be paid if the diagnosis coding clearly indicates that two conditions were treated, Pettigrew says. One ICD-9 code would indicate tendinitis of the knee (726.64, patellar tendinitis), while the other would designate tendinitis of the shoulder (e.g., 726.11, calcifying tendinitis of shoulder).

The rationale for providing two injections is less obvious when they are given in the same joint but on different sides (i.e., the left hip and the right hip). Of course, coders would still report the diagnosis code to indicate the medical necessity for the injections. However, a modifier would be appended to the procedure code to alert payers that circumstances dictated the need for both injections.

Medicare carries recognize the -RT/-LT modifiers (right/left) in instances like these, Pettigrew says. However, for non-Medicare payers, a CPT modifier should be reported. Coders may add modifier -50 (bilateral procedure) to tell the payer why both services were performed, she says.

Alternately, some payers may require that modifier -59 (distinct procedural service) be assigned to the second procedure to indicate that the injections were in separate joints and medically indicated. However, CPT notes that modifier -59 should be used only when a more descriptive modifier is not available. Because various claims processing systems read modifiers differently, coders should check with individual payers if claims reporting modifier -50 or modifier -59 are not paid.

Coding Injectibles for Optimum Payment

In most situations, Medicare and other insurers will reimburse family physicians for the medications provided during joint injections. However, the drugs will be reimbursed only when reported with specific diagnoses. A diagnosis of arthritis or tendinitis, for instance, must be used in conjunction with methylprednisolone acetate (J1020-J1040, depending on dosage). Lists of which diagnosis codes indicate medical necessity for specific drugs are available from most carriers.

In addition, coders must recognize that Medicare will pay only for the injection of a therapeutic drug, not for painkillers. Medicare policy notes that it will cover the medication intended to treat the illness or injury, but not for substances used as anesthetics during the procedure, Pettigrew says. An example of this, she says, is the use of lidocaine during an injection procedure.