Wiki E/M risk level with joint injection

If a patient presents for an E/M of shoulder pain and the provider determines that the patient needs to receive a joint injection, is the risk (ie, minor surgery with or with risk factors) taken into consideration in the E/M? Or is the risk inclusive to the injection and considered double-dipping if counted). Can anyone provide a response as well as a resource link? Thank you.

Good question.
First you have to decide if the documentation supports a separate E/M with modifier 25 or not.
If yes, then is it with or without identified risk (to the patient) factors.
The risk part of the MDM is the decision to perform it. To me, the AMA CPT E/M is the resource. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf "For the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter"

This might help explain a scenario. https://www.aapc.com/discuss/thread...joint-injection.201098/?view=date#post-551197
Please also search the forums for Modifier 25, major joint injection, 20611, 20610, E/M with injection and terms like that.
It depends on the documentation. There is no 100% yes/no on this.

There could be a # of scenarios.
If the patient is established and returned solely for an injection planned at a prior visit, there is no E/M. The work of the injection includes pre, intra and post service work.
If it is an established patient with a new problem, a full workup was done, say an X-Ray, exam, etc. and the provider decides on a major joint injection.
An established patient with a known problem such as OA of the shoulder who routinely comes in for injections every 6 months, for example. It depends. If it is a quick routine thing with no changes, that may or may not warrant an E/M.
If there is a separate E/M documented, and the documentation also supports deciding to do a major joint injection, it is probably decision regarding minor surgery either with or without identified patient or procedure risk factors. The risk has to be specific to the patient and it has to be documented.

I know that's a long answer, but it is really dependent on the documentation. Never 100% Y or N either way.

Old but same idea applies: https://www.kzanow.com/coding-coaches/office-visit-injection-can-bill-modifier-25

The pre-service work of the injection is things like, positioning, prep, cleaning area, topical anesthesia, etc.

Ami‘s answer is comprehensive, but I would simplify it as such;

The “E&M” component of the injection procedure is merely to confirm the plan, and briefly review risks, benefits, and alternatives, and to similarly and briefly discussed expected outcome.

The evaluation of the patient, determination of diagnosis, discussion of options and decision to perform the injection is in no way part of the injection procedure itself.

There are some third-party payors who are aggressively trying to deny legitimate E&M services on the same day as an injection. This goes directly against CMS policy, since there is already a target on the back of 25 modifiers, it is important to encourage your practitioners to document the separate and identifiable nature of their E&M service.