Wiki E/M Follow-up with Injection

[adunlap23]

I am new to E/M coding and have a pretty basic question.

The patient was initially seen for Right shoulder pain, and an MRI was ordered during (this was the previous visit).

The patient has now returned for a follow-up where the doctor reviews the MRI (performed at another hospital) and discusses the findings of the report. He diagnosis the patient with Calcific tendinitis and gives the patient an injection in the shoulder to treat the problem. He also refers the patient to Physical therapy with a brief plan of increased function, pain relief, activities of daily function and education.

My question is, do the MRI interpretation and physical therapy referral count as "significant and beyond the normal preoperative and postoperative work", thereby qualifying the E/M code to be billed with modifier 25? Or do they qualify as services typically associated with the 20610 procedure?

I've seen a few fact sheets on the appropriate use of modifier 25, but I've never really found out what the terms "significant and beyond normal preoperative and postoperative work" means.

 

[Queizati]

I am in a similar situation currently for an encounter where the patient followed up in the office after canceling a previously scheduled injection. After a brief history and MRI interpretation, they proceeded with the injection. The MD documented the patient is to continue OTC medication.

In your scenario, with the information provided, I would count the physical therapy referral as a separate E/M service due to the addition to the patient’s care plan.

The AMA has put out a document for guidance on the use of modifier 25 and what the pre and post-operative work typically consists of.

I am on the fence though regarding the imaging interpretation as being able to stand on its own as a separately identifiable E/M service, due to pre/post op work including the formulation and explanation of the clinical diagnosis.

https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf

Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:

— Review of patient’s relevant past medical history,

— Assessment of the problem area to be treated by surgical or other service,

— Formulation and explanation of the clinical diagnosis,

— Review and explanation of the procedure to the patient, family, or caregiver, — Discussion of alternative treatments or diagnostic options,

— Obtaining informed consent,

— Providing postoperative care instructions,

— Discussion of any further treatment and follow up after the procedure.

 

[adunlap23]

I am in a similar situation currently for an encounter where the patient followed up in the office after canceling a previously scheduled injection. After a brief history and MRI interpretation, they proceeded with the injection. The MD documented the patient is to continue OTC medication.

In your scenario, with the information provided, I would count the physical therapy referral as a separate E/M service due to the addition to the patient’s care plan.

The AMA has put out a document for guidance on the use of modifier 25 and what the pre and post-operative work typically consists of.

I am on the fence though regarding the imaging interpretation as being able to stand on its own as a separately identifiable E/M service, due to pre/post op work including the formulation and explanation of the clinical diagnosis.

https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf

Thank you. I printed the AMA document you recommended. This was very helpful.