Wiki Coding an E&M code on the same day as an injection of depomedrol

[jlcheritage]

Our doctors are concerned over the issue of coding an office visit on the same day. the question is, if the patient comes in and presents with pain and swelling of the knee and the doctor decides to do an injection/aspiration on the same day, can we bill the office visit with a 25 modifier and the injection? Or do we just bill for the office visit and not bill the injection code of 20610.
Does the doctor need to have a separate issue to bill the office visit or can the office visit be billed with the pain in the knee then the effusion dx for the injection.

 

[Leenahz]

Yes, an office visit with modifier 25 needs to be "separately identifiable."

I would do a search on the forums, I know there's been several discussions relating to this, for more in-depth clarification.

Welcome to the forums
Lena