Primary Care Coding Alert

Answer: The CPT manual outlines the codes for specific types of joint arthrocentesis, injections and/or aspiration: 20600* for minor joints such as fingers and toes; 20605* for intermediate joints such as wrists, elbows or ankles; and 20610* for major jointsshoulders, hips and knees.

1. A patient visits the doctor because she is suffering from a cold, but she also has tennis elbow requiring an injection. The doctor can code for the E/M office visit (99213) with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), along with 20605* (injection into an intermediate joint, bursa, ganglion cyst, including wrist, elbow or ankle), and the appropriate J code for the injectable medication, not for a local anesthetic, says Laura Nuechterlein, a senior policy analyst with the American Academy of Orthopaedic Surgeons.

2. If the patient decides to return the following day for the injection, or requires a second injection at a different time, only the procedure code for the shot and the medication itself can be billed. The one exception in which an E/M may be billed on the second visit is if the doctor is surprised by the recurrence of swelling of the joint and has to do an additional examination, says Quin Buechner, CPC, a coding consultant with Webster Rogers & Company, a medical coding consulting firm in Florence, S.C.

If a patient comes into the office with a swollen elbow but not specifically for an injection, Medicare still allows the doctor to bill for both the E/M and the procedure, as described above, even though the office visit and the injection have the same diagnosis codes.

3. If the physician knows that a patient may have to return for several injections for the same problem over a short period of time, he or she should use modifier
-58 with the staged or related procedure, Buechner says. Although modifier -58 (staged or related procedure or service by the same physician during the postoperative period), is not used too often, CPT says: The physician may need to indicate that the performance of a procedure or service during the postoperative period was a) planned prospectively at the time of the original procedure; b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure.

4. J codes are applied to the use of injections depending on the specific medication. The HCPCS manual, however, clearly indicates which injectables Medicare wont cover and which ones are at the discretion of the carrier. Medicare will cover the following:
they cannot be self-administered;
they are not excluded by being immunizations;
they are reasonable and necessary in the diagnosis or treatment of the illness or injury for which they were administered;
the FDA has deemed their effectiveness; and
they must meet all the general requirements for
coverage of items as incident to a physicians services.

Unfortunately, Medicare will not cover any medications used as painkillers during the treatment, but rather only those intended to treat the illness or injury.