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 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 [...]