pvrossow
New
Procedure: Right HIP ARTHROGRAM/INJECTION
After obtaining informed consent, the patient was prepped and draped in a sterile manner on the fluoroscopy table. 9 cc's of local anesthetic was given. Under fluoroscopic guidance, using an anterolateral approach and a 20 guage needle, the needle tip was placed along the lateral one-third of the femoral head/neck region. Intraarticular placement was confirmed using a 2 ml solution of Isovue mixed with 3ml of normal saline. Then a mix of 2 ml 1% lidocaine, 6 ml of .25 marcaine, 3ccs saline and 0.2 ml of Multihance was injected into the hip joint. The patient tolerated the procedure well. Hemostasis was maintained then a band-aid was affixed.
The right hip was examined following the procedure. She reports unchanged groin pain with FABER and no pain with FADIR. She was able to weight bear and ambulate without difficulty. She will continue to monitor her symptoms over the next 24 hours and report back to her ordering physician.
___________________________________________________________________________
The red statement was coded as:
I audited the encounter and made the determination that it was inappropriate to bill and be paid for 99211-25 because the blue statement was not considered a significant, separately identifiable service that is above and beyond the usual pre- and post-operative work of the procedure. I state that in this case, the documentation notes that the post-injection exam is directly related to the problem that precipitated the injection, which would not support a separate E/M. If any complications, exacerbations, or presence of other diseases or injuries were determined during the course of this encounter and required additional services, then the documentation would be expected to reflect that, and the required additional E/M services may then be reported separately. For example, if this post-injection exam led to a new diagnosis, and medical decision making around that diagnosis was performed and documented, then I think a separate E/M service would be warranted. However, that doesn’t appear to be the case here.
Who's right here? Thanks for your help!
After obtaining informed consent, the patient was prepped and draped in a sterile manner on the fluoroscopy table. 9 cc's of local anesthetic was given. Under fluoroscopic guidance, using an anterolateral approach and a 20 guage needle, the needle tip was placed along the lateral one-third of the femoral head/neck region. Intraarticular placement was confirmed using a 2 ml solution of Isovue mixed with 3ml of normal saline. Then a mix of 2 ml 1% lidocaine, 6 ml of .25 marcaine, 3ccs saline and 0.2 ml of Multihance was injected into the hip joint. The patient tolerated the procedure well. Hemostasis was maintained then a band-aid was affixed.
The right hip was examined following the procedure. She reports unchanged groin pain with FABER and no pain with FADIR. She was able to weight bear and ambulate without difficulty. She will continue to monitor her symptoms over the next 24 hours and report back to her ordering physician.
___________________________________________________________________________
The red statement was coded as:
- 27093 - Injection procedure for hip arthrography; without anesthesia;
- 77002 - Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device);
- A4550 - Surgical trays, and;
- Q9967 - Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml
- 99211-25 - Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional.
I audited the encounter and made the determination that it was inappropriate to bill and be paid for 99211-25 because the blue statement was not considered a significant, separately identifiable service that is above and beyond the usual pre- and post-operative work of the procedure. I state that in this case, the documentation notes that the post-injection exam is directly related to the problem that precipitated the injection, which would not support a separate E/M. If any complications, exacerbations, or presence of other diseases or injuries were determined during the course of this encounter and required additional services, then the documentation would be expected to reflect that, and the required additional E/M services may then be reported separately. For example, if this post-injection exam led to a new diagnosis, and medical decision making around that diagnosis was performed and documented, then I think a separate E/M service would be warranted. However, that doesn’t appear to be the case here.
Who's right here? Thanks for your help!
Last edited: