Primary Care Coding Alert

Question: An established patient came to our office because of knee pain. Our physician x-rayed the knee during the visit. Should we attach modifier 25 to the E/M code?

Kansas Subscriber

Answer: No, you don't need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in this situation.

Here's why: You're billing for an x-ray and office visit. Like E/M services, x-ray services have an "XXX" global period, meaning the global period concept does not apply, so there is no evaluation or management presumed to be part of the x-ray service. Thus, there is no need to identify the E/M service as "significant and separately identifiable."

If your physician administered a knee injection during the visit to help alleviate the patient's pain, then appending modifier 25 to the E/M service would be more appropriate. As a therapeutic, "000" day global service, the knee injection is presumed to include some evaluation and management of the patient. You denote that the E/M service done by your physician was above and beyond the usual preoperative care associated with the injection by appending modifier 25 to the E/M code. In this situation, you would report the appropriate E/M code from 99212-99215; the correct knee x-ray code from 73560-73564 (Radiologic examination, knee ...); and 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) for the knee injection.