Wiki Billing E/M instead of injection?

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CatchTheWind

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Pt comes in with complaint of rash and is given IM Kenalog injection. Because there was a complete HPI, exam, etc., we could bill the E/M instead of the injection, and the reimbursement would be higher. Is there any coding or compliance reason not to do this?
 
You would bill both the E/M and the injection as well as the drug. Appropriately modify the E/M with 25. The injection wasn't planned when they came in, but rather part of the treatment plan for the presenting problem and if documented appropriately, both can be billed.
 
You would only not bill the E/M and the injection if it was a nurse visit. In that case you must always bill the injection code instead of the E/M
 
I thought that the E/M was "included" in the injection code. However, maybe I'm way off. I'm not very familiar with coding IM injections. We're dermatology, and we frequently perform minor procedures which include taking an HPI and examining the affected body part in the code.

Are you all saying that giving an injection does NOT include the related HPI and exam in the code itself, so if you do these things you can bill the E/M separately?
 
If the patient came in specifically for an injection, then no E & M code is billed. But, if you have to evaluate and figure out what is going on with the patient, and an injection is indicated to treat the medical condition, then you can bill for both. Documentation must support all charges.
 
It is confusing that the decision for surgery is included in other minor procedures but not the IM injections. The reason might be that the vignette used in valuing the IM injection includes little physician work other than ordering the injection and supervising the staff who perform the injection while other services include more physician work including pre-service evaluation of the surgical site, discussion of risks, etc.
 
Per CMS
The E&M services are considered part of the injection procedure unless the situation meets the definition of modifier 25.
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.

So, it is the same as for minor procedures, unless they are going above and beyond what was required to evaluate the patient for the injection and to perform the injection, you would not bill both codes.
 
I had one of these today. Patient came in for chronic neck pain, provider suggested injection, patient agreed. I billed the stick and stuff but not the E/M (even with -25) because the treatment given was consistent with the procedure code.

If the patient had said, "oh and by the way, my allergies are acting up" that would be different. Patients consistently do this which is why you tend to see an E/M with an injection code. Seeing these two together does not mean they ALWAYS go together.
 
So it seems that we cannot bill the E/M, unless we choose to bill the E/M instead of the injection because it pays better. Which leads us back to my original question: Is there any coding or compliance problem with choosing to bill for just the E/M, since that it actually the more major of the two services?
 
Last edited:
CatchTheWind,

Please understand the CPT guidelines and Medicare rules state we are to select and report the code that BEST describes the service performed. To select a code that does not describe the service performed because it "pays" better is the definition of what we are NOT to do under the False Claims Act.
.... knowingly submitting false or fraudulent claims to the government for payment or making or using a false record or statement in connection with the submission of such claims.
~False Claims Act (31 USC 3729-3733)

Summary:
Everyone above has focused on our first thought when reading your posting that you cannot bill an injection with an E&M when that procedure is pre-planned. There must be a separate problem or a significant E&M and that does not appear to be happening in your circumstance. You would only bill for the injection and the drug when the service is pre-scheduled and possibly even if performed on the same day as an initial evaluation as a brief E&M is inclusive to the injection.
 
We would never bill for a service that was not performed! In this case, we performed two services, but because they were for the same problem, we can only bill for one or the other, not both!

But in further researching this, I found another post on the forum in which Mitchellde says: "If the visit is to evaluate an ill individual and in the course of the evaluation then an injection is administered you may bill the office visit with a 25 modifier and the 96372 with no modifier." (See https://www.aapc.com/memberarea/forums/showthread.php?p=231473)
 
Not if you are billing Medicare
"The E&M services are considered part of the injection procedure unless the situation meets the definition of modifier 25.
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed"
Evaluation of the patient to determine the need for the procedure is considered part of the procedure by Medicare, unless the provider is doing something outside the norm.
 
cheermom68 said:
Not if you are billing Medicare
"The E&M services are considered part of the injection procedure unless the situation meets the definition of modifier 25.
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed"
Evaluation of the patient to determine the need for the procedure is considered part of the procedure by Medicare, unless the provider is doing something outside the norm.
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What if a detailed history was taken and like 6 body areas were looked at then a keloid injection was performed for a new patient. Would that be 99202 or 99202-25 & 11900.
 
JesseL said:
What if a detailed history was taken and like 6 body areas were looked at then a keloid injection was performed for a new patient. Would that be 99202 or 99202-25 & 11900.
Click to expand...


You shouldn't count bullets just because they are there. They have to be related to the CC or at least be referenced in some part of the note as being relevant to the nature of the presenting problem(s).

E&Ms are an integral part of a minor procedure (the RVUs were adjusted accordingly awhile back), so that unless some significant issue that is over and above what would normally be done to evaluate the patient for a minor procedure is performed, then you'd bill only the procedure. You shouldn't bill just the E&M because it pays better.

Also, be careful of looking back into this forum. This scenario was part of a CCI edit change just a short while ago....so old posts may be out-of-date guidance.
 
If the exam is relevant to the presenting problem or the provider can relate the necessity of the more indepth exam, and then discovers the keloid and after discussion with the patient decides to remove it then you have both the E&M and the removal. However if the patient schedule the encounter specifically for a removal of the keloid then it does not matter if the patient is new or established, the E&M is considered to be part of the removal as the medical necessity for the removal had already been determined prior to this encounter. If the provider sees something amiss and decides to perform a more detailed exam, then the necessity for this must be clearly revealed in the note.
 
The global period concept does not apply to IM/subcut. injections so you cannot look at this as you do procedures that are assigned a 0 or 10 day global (ie, have pre-service physician work). The only physician work included in an injection is confirmation of the order for the injection and supervision of the staff who perform it. If you can find the CMS articles from around 2004 when this physician work was assigned to the injection and chemotherapy services, I think you will find that CMS indicates that modifier 25 is required to prevent reporting of an E/M service for supervision of these services when no other physician E/M is provided on that date. This is not the same as the use of modifier 25 with a procedure that includes pre-service physician work.
 
Cynthia Hughes said:
The global period concept does not apply to IM/subcut. injections so you cannot look at this as you do procedures that are assigned a 0 or 10 day global (ie, have pre-service physician work). The only physician work included in an injection is confirmation of the order for the injection and supervision of the staff who perform it. If you can find the CMS articles from around 2004 when this physician work was assigned to the injection and chemotherapy services, I think you will find that CMS indicates that modifier 25 is required to prevent reporting of an E/M service for supervision of these services when no other physician E/M is provided on that date. This is not the same as the use of modifier 25 with a procedure that includes pre-service physician work.
Click to expand...

Does that mean we can bill for both em and injection then if the provider see's the patient for the first time for a single problem and then decides to do an injection since there's no preservice for injections?
 
I code for a primary care clinic and our providers order IM injections frequently, for allergies, pain, sinusitis, etc..... If a patient comes in with neck pain, the provider will do an eval and exam before ordering an injection. In this case an E/M code is assigned with a modifier -25 as well as the admin code and code for the meds injected. Your provider wouldn't just give a patient a pain med injection without examining the patient unless orders were given previously for the patient to come in for the injection given by a nurse.
 
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