Primary Care Coding Alert

Question: A patient came into the office to see our FP to receive a knee injection. The patient has had injections from this physician in the past. Can I use modifier 25 on this claim?

New York Subscriber

Answer: If you have sufficient history, exam, and medical decision making (HEM) to support billing a separately identifiable evaluation and management service in addition to the joint injection, you can use 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) appended to the appropriate E/M code on this claim.

The E/M service should be separately identifiable from the injection. You’ll report the E/M service using the appropriate established patient code from the range 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) range, since this patient has seen the physician in the past and assuming that encounter was in the last three years.

Keep in mind: All procedures include some level of E/M that result in HEM. The physician needs to clearly document that he performed more than the history, exam, and medical decision making typically included with every injection if you are also reporting an E/M code using modifier 25. In other words, you should be able to “carve out” the service that was unrelated to the injection to get the level of service for the E/M code you will bill.

Example: An established patient with a documented diagnosis of knee arthritis presents two weeks after her prior visit for a scheduled knee injection. She states that she now also has pain in her shoulder. After an examination, the physician determines she has bursitis or tendonitis in the shoulder. The physician then administers the knee injection for the previously diagnosed arthritis. 

Because the documented work of diagnosing the bursitis/tendonitis would likely be enough to justify reporting an E/M service, even in the absence of the knee injection, it is appropriate to use modifier 25 to seek separate payment for the E/M visit for the shoulder pain. The fact that the E/M is for a new diagnosis, unrelated to the previous diagnosis of arthritis, further supports that it was significant and separately identifiable from the joint injection, although an E/M with modifier 25 appended may be prompted by the symptom or condition  for which the procedure was provided. 

Bottom line: If you do not see “extra” history, exam, and medical decision making that support a separate service, you should only bill the injection code.