Wiki trigger point inj and prolonged svcs

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ppt

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Pls help if the following coding is correct?

cc: patient presents today for trigger point.

the rest of document was canned from previous note. She wants me to bill
99212-25 20553 and 99354 because she monitors patient for 30 mins after the injection if there is any reaction or side effect to the inj. I dont agree w/her because monitoring patient after the inj is part of 20533.

can someone give me some advise.

thanks
ppt
 
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the 99354 can only be appended to the E&M not procedure codes and only if the E&M service is timed separately from the injection service, so she would have needed to document 45 minutes or more with the patient face to face the entire time and then the procedure note as a separate entity. ALso you state the note was "canned" as in pasted over? So the procedure was scheduled from a prior encounter? if so then the only thing you can bill is the procedure and you are correct any necessary observation is inclusive to the procedure. If the provider feels the circumstances for this particular patient with this particular procedure need service beyond the ordinary , then the procedure note must state this and why this case case had extenuating circumstances, then you may apply a 22 modifier to the procedure code.
 
Great answer from Debra, as always; I have a follow-up question to this situation...In order to bill for the Prolonged time, wouldn't the MD have to remain in the same room with the patient for the time documented monitoring the patient (30 minutes)?......not likely to happen, at least with my docs! :D
 
Great info here! I have a question on billing E/M along with the injections. To me it is a bit questionable that there is really an E/M - it seems the patient is just coming in for the injections. What do you think?

Medical history: Chronic back, shoulder & neck pain with headaches from catching a patient who was falling.

CC: Pt states having a lot of pain in neck & shoulders.

History: patient has been diagnosed with trigger points at a previous OV and TPI have been ordered as treatment. Previous TPI have been found to be effective in reducing regional pain in this patient.

Exam/Assess: M/S: Myofascial pain palpated at points described below:
(using check boxes)

Cervical:
723.9 (5 muscles listed)
726.19 (1 muscle)
Thoracic:
723.9 (1 muscle)

TPI: Trigger points identified as above and prepped with rubbing alcohol.

(another check box) Trigger points injected with 10ml 0.25% Marcaine.

*********
Billed with Dx above as:
99212-25
20553
S0020x1
 
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It does not look to me that you have a significant and separately identifiable Evaluation and management.
You have the most minimal of exams documented along with the skinniest of procedure notes. IMO you bill the procedure only.
Megan: Yes the provider would need to document that all time stated was spent face to face with the patient.
 
I'm thinking the statement alone in the History portion would support the office visit as not being reportable It does not fulfill the "significant and separately identifiable" criteria for modifier 25.
 
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