Primary Care Coding Alert

Question: An established patient came in for continuing lower back pain. The FP took an interval history and performed an examination. Because the patient's prescribed medication and recommended exercise regimen were not alleviating the pain, the physician discussed other management options with the patient, including suggesting trying trigger point injection (TPI). The FP discussed the procedure's benefits and risks. The patient decided to try an injection.

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Answer: Provided the FP documented the history, examination, and medical decision making, hopefully in a separate paragraph from the injection procedure and plan note, you may report the office visit (99212-99215, Office or other outpatient visit for the evaluation and manage-ment of an established patient -; 724.2, Lumbago) appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) in addition to the injection (20552, Injection[s]; single or multiple trigger points[s], one or two muscle[s]; 724.2). Also, don't forget to report the appropriate code from the series J1020-J1040 (Injection, methylprednisolone acetate -) for the Depo-Medrol; the appropriate code will depend on how much Depo-Medrol was injected. The documented skill set that the FP employs prior to the decision for TPI is the differential that supports reporting the modifier 25 appended visit code. CPT does not require an E/M-25 service to have a different diagnosis to be separately billable from a same-day procedure.

Typically, you may report an E/M for an encounter in which the patient receives an injection that was not planned at the time of the visit. When the patient comes back for another injection, and the FP treats no other problem or condition, you won't usually code an E/M-25. To report an E/M, the history, examination and medical decision-making must be above and beyond the minor evaluation and management that is associated with providing the TPI.