Wiki Billing an EM w/ small joint injection

[arkolab]

Looking for thoughts on the below note. This is a new patient to the provider. The MD is trying to bill a 99214 in conjunction with the injection CPT 20600. Does the documentation support billing a 99214/99204 with the injection given at this visit?


HPI: with a chief complaint of pain/tenderness associated with mass located at the left SF PIP. Evaluation to date has included visit with PCP, XR. Treatment to date has included activity modification. The symptoms are improved by rest/avoidance and exacerbated by bumping it. The current symptoms are rated severe. Denies numbness/tingling.

they report that they have never smoked. has never been exposed to tobacco smoke. has never used smokeless tobacco.

All past Medical, Surgical, family, Allergy history has been revied. Along with current medications.

ROS:
GENERAL: Negative for malaise, significant weight loss, fever/chills
HEENT: No changes in hearing or vision
RESPIRATORY: Negative for cough or wheezing
CARDIOVASCULAR: Negative for chest pain or palpitations
GASTROINTESTINAL: No change in bowel habits
GENITOURINARY: Negative for change in urinary habits
NEUROLOGIC: Negative for dizziness or syncope
SKIN: Negative for skin changes
PSYCHIATRIC: Negative for recent psychosocial stressors
HEMATOLOGIC/LYMPHATIC: Negative for lymphadenopathy

PHYSICAL EXAMINATION:
Vitals: BP 152/92 | Pulse 94 | SpO2 98%
General: healthy appearing patient. No acute distress.
Psych: Affect normal. Conjugate gaze.
Eyes: Sclera clear. Tracks appropriately
ENMT: Ears and nose atraumatic. No rhinorrhea.
Cardiac: Regular rate by peripheral pulse palpation. Regular rhythm.
Respiratory: Unlabored on room air. No audible wheezing.
Lymphatic: No palpable lymphadenopathy. No lymphedema.
Skin: No rashes, lesions, or induration by inspection or palpation.

LUE:
No open wounds. Severe tenderness to palpation L SF proximal interphalangeal joint. Small firm mass present.
Equal and intact sensation in radial 3 digits and ulnar 2 digits.
Dorsal wrist mass, non-tender

IMAGING:
X-Ray: as interpreted by me, shows post-traumatic osteoarthritis proximal interphalangeal joint

LABS, TESTS, DIAGNOSTICS, & RECORD REVIEW: records reviewed from PA at outside facility

ASSESSMENT: Degenerative arthritis of proximal interphalangeal joint of little finger of left hand (primary encounter diagnosis)
Chronic wrist pain, left
Mass of wrist, left
Digital mucinous cyst of finger

PLAN: I discussed with patient the diagnosis and my impression, its etiology, and different workup and treatment options, including wrapping and surgical excision, we discussed arthroplasty and injection as well as risks. We discussed different management options and the risks/benefits of each. We discussed expectations and prognosis. We discussed the joint and cyst considerations as well as recurrence. After this detailed discussion, the patient is electing for injection which is performed. Wrist XR ordered on the way out.

The risk, benefits, and alternatives of injection and no injection therapy were discussed, including the risk of infection, hypopigmentation, fat atrophy, tendon rupture, and blood glucose elevations seen with diabetes. The patient verbally consented for an injection and a timeout was done to confirm patient name, birthdate, and injection site. The injection site was prepped with a alcohol swab. The left small finger proximal interphalangeal joint was injected from dorsal location via 27-gauge needle with Kenalog (20mg), and 1/2mL xylocaine plain 2%. The injection site was then dressed in a band aid. The patient tolerated the injection well. The patient was instructed to call the office if any adverse local effects occurred or any if any questions or concerns arise.

 

[NRaizman]

First of all, this is absolutely a separate E&M service from the injection. It should be reported with a -25 modifier.

Secondly, no medications were given and the procedure is a minor one with no identified patient risk factors, and the documentation of data reviewed/tests ordered does not reach moderate level, so I do not see the justification for a level 4 visit - I would consider this to be level 3. You could argue that independent interpretation of the XR counts, but if the PA is associated with the same practice that would be kicked out

 

[arkolab]

First of all, this is absolutely a separate E&M service from the injection. It should be reported with a -25 modifier.

Secondly, no medications were given and the procedure is a minor one with no identified patient risk factors, and the documentation of data reviewed/tests ordered does not reach moderate level, so I do not see the justification for a level 4 visit - I would consider this to be level 3. You could argue that independent interpretation of the XR counts, but if the PA is associated with the same practice that would be kicked out

XR was ordered and independently interpreted by the same provider, prior to the official read from radiologist (we don't have a reading radiologist on site)

What if this were to be an already established patient who has been seen prior, and the doctor went over different management options at previous visit?

 

[NRaizman]

XR was ordered and independently interpreted by the same provider, prior to the official read from radiologist (we don't have a reading radiologist on site)

What if this were to be an already established patient who has been seen prior, and the doctor went over different management options at previous visit?

If XR was ordered and independently interpreted, I think that keeps this as a level 3. Or you bill the XR separately depending on if this is an independent clinic or part of a facility.

In the second hypothetical, if the doctor had already evaluated the patient, made the diagnosis and discussed management, then you can’t bill for an E&M subsequently when all you do is the injection.

This is a matter of clear and convincing documentation - all around the country, 3rd party payors are vigorously attempting to deny E&M’s on the date of an injection. CMS proposed it in 2018 but the backlash in comments made them back off and it was never finalized, but that didn’t stop private payors from trying to weaponize the PFS Proposed Rule. Your docs should code a separate E&M -only when appropriate- and there needs to be clear documentation of a change in patient status, an evaluation of the condition that is more than just confirming the prior diagnosis, and a discussion of treatment options beyond just the injection. You can look at the CPT Manual for discussion of what E&M is considered bundled into a procedure, as well as the NCCI Policy Manual.