Wiki E/m with decision for injection

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MARY K

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Currently when a new patient with a chief complaint of knee pain comes into our office for the first time and after an exam of knee, pt is diagnosed with arthirits of the knee and decision for a knee injection is made, we code an appropriate new patient e/m with a 25 modifier and cpt 20610 for knee injection. We are now being told this is wrong, that e/m is included as part of injection global. Is this correct have we been billing this wrong
 
If the doc is expecting payment separately for making a decision that pt needs injection then this is wrong, Because the outcome of EM is need of injection, and if doc itself had given injection then he can bill the EM and the injection code.

Hope that helps.
 
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If the patient came to the office without an expectation of getting an injection, an only after an examination the provider determined that an injection is needed then yes you may bill both, assuming the documentation is good enough.
The injection code includes the assessment of the patient necessary to perform the injection. In other words the provider cannot perform the injection with a blindfold on.
If the documentation provides information that is over above and beyond the necessity to give the injection then you may bill the visit also.
This is not a comprehensive history, this is the assessment, such as assessing the other knee and other joints.
Then when the patient returns for the next scheduled injection, you cannot bill the E&M since the assessment of the other areas has already been performed and the patient is not complaining of anything else.
 
Yes - Deb nailed it (as usual)

The key distinction here is whether A) the Injection was the purpose for the visit, or B) the provider had to do a medical evaluation first, and then determined that an injection was needed. Since this is a new patient, it's likely that scenario B applies, in which case you can certainly bill for an E/M service with modifier 25 in addition to the injection procedures assuming both services are performed and documented sufficiently and are distinct, separately identifiable services. There's nothing wrong with that.

Now, if the patient has an appointment to come back in 3 months for another injection, and there is a brief assessment before the injection is given, that assessment is included in the procedure so you should not bill an E/M plus the injection for that. There is a certain E/M component that is inherent to all surgical procedures (not necessarily talking about procedures in the Operating Room, but talking about all procedures in the surgery section of CPT) so it wouldn't be appropriate to add an E/M code to the injection just because the provider did a brief history and assessment before the procedure.
 
Correct coding does not always mean you will get paid

Keep in mind that different payers have different policies. Just because it is coded correctly does not meant they have to pay for it.

I'm not saying you shouldn't challenge it, I'm just saying it may end up just being a payment policy issue rather than a coding problem.

Laura, CPC, CPMA, CEMC
 
Of course, that caveat comes with all the advice you see on this forum. We can only really discuss 'coding theory' but when it comes to using these codes in the real-world, each payer may have their own defined policies that you will have to follow. Some insurances won't cover 2 services on the same date, whether there is a modifier or not.
 
Food for thought...effective 1-1-2013

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.

http://www.cms.gov/Medicare/Coding/...ect=/NationalCorrectCodInitEd/NCCIEP/list.asp
 
Interesting, thanks for posting Rebecca!

I have always taught this and coded this way since I was taught all procedures include a little bit of E/M. If you are using that 25 it had better be significant and separately identifiable! I have gotten push back from other coders over the years with the new patient scenario though.

Thanks again,


Laura, CPC, CPMA, CEMC
 
LLovett said:
I have always taught this and coded this way since I was taught all procedures include a little bit of E/M. If you are using that 25 it had better be significant and separately identifiable! I have gotten push back from other coders over the years with the new patient scenario though.

Thanks again,


Laura, CPC, CPMA, CEMC
Click to expand...

Happy to help, Laura! ;)
 
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