Primary Care Coding Alert

Question: Our provider saw a patient who was experiencing shoulder pain. The provider decided to treat the patient’s pain with medication but told the patient if the pain did not improve, the patient should come back for a joint injection. A month later, the patient called and said the pain was still occurring, so we scheduled the patient for the injection, which the provider administered. In addition to the 20610, can we also bill for an evaluation and management (E/M) visit for this second encounter?

Idaho Subscriber

Answer: In the second encounter, your provider did not evaluate the patient’s shoulder — that was performed at the patient’s first visit. Additionally, the provider managed the patient’s condition at that first visit by prescribing medication and identifying further treatment in the form of the injection should the medication prove ineffective.

None of this took place at the patient’s second visit, however, and the only medical decision making (MDM) your provider engaged in was to go ahead with the 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) service. As the MDM involved in that injection was not significant and separately identifiable from the MDM typically associated with the injection, you cannot report a separate E/M service, and you should only bill the 20610 on this occasion.