Orthopedic Coding Alert

Satisfying Medicare for Office Visit and Injection Coding


- Published on Mon, Nov 01, 1999

A Medicare patient visits an orthopedic surgeons office for preoperative care that requires an injection. The service or procedure the patient requires is identified by a CPT code.

Coding is straightforward. For example, the CPT code 20610 (injection, major joint or bursa) or 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst) is reported along with the HCPCS J code to indicate the drug administered.

But the situation changes when the patient identifies a new symptom during the visit and the symptom requires retaking the history and an exam. Evaluation and management (E/M) services are necessary. Can the physician bill for the office visit requiring E/M services and for
the injection?

The short answer is yes. The longer answer is, In most cases, but be careful.

Many Payers Want Separate Diagnoses

Carol Ethridge, CPC, a coding and reimbursement specialist and the president of the Birmingham South chapter of the American Association of Professional Coders (AAPC), explains: An office visit with a separate identifiable diagnosis, and with a modifier 25 attached to the visit, may be billed [in addition to] the joint injection.

Technically, the 1999 CPT does not require separate diagnoses (cf. below, Clarifications). But they help to simplify the interaction with payers.

That is because a stumbling point when billing for E/M services and injections during an office visit is the distinctiveness of the symptoms. A new symptom (beyond the usual preservice and postservice care associated with the procedure performed, according the 1999 CPT) is a must. And the easiest way to support such a symptom is with a new diagnosis code.

Some scenarios are relatively clear-cut. A patient visiting the physician for a knee injection complains of shoulder pain. When the physician responds to the complaint by performing range-of-motion tests on the shoulder, the -25 modifier (significant, separately identifiable E/M service by the same physician on the day of a procedure) can be used.

Multiple Symptoms, One Diagnosis

Payer response becomes less predictable if the patient complains of a new symptom, such as a different kind of problem (e.g. weakness instead of pain) in the knee that is getting the injection. Will the criteria required for use of the -25 modifier be met?

The -25 modifier should apply, even if the diagnosis is the same, says Brett Baker, a regulatory affairs associate and third-party payment specialist at the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in Washington, DC. Baker looked closely at the revised E/M services guidelines in the 1999 CPT, and wrote about them for members of ACP-ASIM.

He points out that a paragraph was added to the 1999 CPT, which reads in part: The E/M service [...]

Orthopedic Coding Alert
Issue - Nov, 1999
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