Primary Care Coding Alert

Question: A patient recently seen in our practice was suffering from tendonitis (i.e., 726.90, enthesopathy of unspecified site) and required cortisone injection therapy. Can we bill for the evaluation and management (E/M) service, plus the injection therapy?

New York Subscriber

Answer: To bill for both an injection and an E/M service, the family physician would have to see the patient for a significant and separately identifiable visit.

For example, a patient makes an appointment because he is suffering from severe seasonal allergies (477.0, allergic rhinitis; due to pollen) and, during the course of the visit presents symptoms requiring a trigger point injection (20550, injection, tendon sheath, ligament, trigger points or ganglion cyst). The family practitioner may report the injection in addition to the appropriate level E/M code, which 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). In addition, your practice may report the medication as well (J0810, injection, cortisone, up to 50 mg). Both the E/M and the injection can be billed even if the diagnosis for both services is the same. The requirement is that the E/M service must be above and beyond that usually provided in conjunction with the injection.

However, if the patient were being seen only for the injection, your physician would report only the injection code and the J code.