Orthopedic coders report that carriers have recently started refusing to pay for E/M visits on the same day as joint injections, even when the doctor performs separately identifiable work.
Example: A patient complaining of elbow pain (719.42, Pain in joint; elbow) visits the physician. The orthopedist diagnoses the patient's pain as arthritis (such as 715.12, Osteoarthrosis, localized, primary; elbow) and administers a joint injection (20605, Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa).
The physician should be able to bill for both the E/M and the injection, says Ryan Price, CPC, CCS-P, manager of coding operations at Aviacode, a coding outsourcing company in Salt Lake City. Separate Diagnoses Aren't Necessary Problem: The only way that many carriers will pay for the separate E/M without a hassle is by using a different diagnosis. When this is an option, you should report both ICD-9 codes, because they better describe the reason the physician performed two services.
Caution: In our example above, you couldn't simply list "elbow pain" for the E/M and then the more definitive diagnosis of arthritis for the injection, because this goes against ICD-9 reporting guidelines.
These guidelines state, "Codes that describes symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the physician," but "signs and symptoms that are integral to the disease process should not be assigned as additional codes." Therefore, because the patient's condition has been diagnosed as arthritis, you should no longer report elbow pain.
But even if you don't have separate diagnosis codes, as long as you perform a separately identifiable, medically necessary E/M service, you should still report both the E/M and the injection. Append -25 to E/M Code Although reporting two separate diagnoses - one for the injection and a different one for the E/M visit - will help cinch your reimbursement, separate diagnoses aren't required by CMS standards. As long as you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, you can report both services with the same diagnosis code when necessary.
Example: A new patient presents and complains of knee pain. The orthopedic surgeon performs a level-three new patient evaluation and administers a joint injection (20610, Arthrocentesis, aspiration and/or [...]