Every injection or decision for injection is not a level 4 just because they decided on an injection. If coding by MDM they have to have 2/3 elements, not just 1/3. Even
if they had documented minor procedure with risk specific to the patient (OA (B) knee, major joint injection w/ US, pt diabetic), they would still have to meet another one (chronic exacerbated).
AND, the work of the injection is excluded because there is E/M component in every injection. If it is a new patient, and they documented correctly for the E/M, and it supported an injection, and it met modifier 25 you could possibly bill all at the same visit. It's not to say it never happens. This is not an all or nothing scenario though. You can't just blanket call every injection decision level 4! It is definitely not an E/M if the decision was made at one office visit and the patient came back SOLELY for the purpose of an injection (Visco, PA joint injection only). They don't automatically get another level 4.
It is a common issue especially in ortho groups. I understand your struggle. I had providers that thought (and coded) every single visit as a level 5... Every single visit 5 had to be touched and reviewed by a coder...
A suggestion is to separate the two procedures or whatever procedures and services were done at the visit. If you use the "cross out" method, is there enough left for each service to be supported by the documentation?
This doesn't even include the question of whether or not Modifier 25 is supported by the documentation for performing an E/M and injection at the same time. Since the injection (20610, etc) codes live in the surgical section of CPT, they have pre, intra, and post-service work involved. Meaning the RVUs include some piece of history, exam of the area to be injected, performance of the injection, and result or patient disposition after. This is all included in the injection.
You can also
talk to them in dollars. What does their provider dashboard look like monthly or quarterly (you may have to get help from the CFO or data analytics folks). How many rejections at clearinghouse level or payer level, denials, and take backs are you receiving from payers after the fact? Are you under pre-pay review by any payers? Are you getting records requests and ADR requests or TPE notices? Why would they want to put themselves and the practice at risk? Other times in my experience, we actually had to get external auditors in to literally tell them the exact same thing we were beating our heads against the wall with, and guess what...they listened to the external auditor. LoL. If they still won't listen it's their name on it, but if you have an audit plan you have to follow AMA or CMS or whatever your internal policy is.
You noted they are billing and being paid separately for the X-Rays/MRI so you can't double count that in the E/M.
A lot of times, in talking with ortho providers, they really may be doing the work of a 4 or 5 however, they are not telling the story or connecting the dots on "paper" in their documentation.
Old but has good info, just found googling:
https://multibriefs.com/briefs/coaorg/p1.pdf
(Novitas may not be your MAC but good info):
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00005056
"3.
How do you bill E/M services performed on the same day as other services?
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service).
E/M services may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery; see modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
For more information and proper usage of modifier 25, please refer to
Modifier 25 Fact Sheet and
Modifier 25 Tips.
4.
How does Novitas review an E/M billed with modifier -25?
Modifier -25 is used to report significant and separately identifiable E/M services by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, we will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. We also consider the additional documentation for the additional service separate from the documentation specific to the initial procedure or service to determine:
If there is a significant, separately identifiable E/M service that was rendered and documented, and
If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and
If the level of care is supported by the documentation contained in the medical records."