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Billing for Modifiers

Article

Your article in the February issue of Physicians Practice about "better coding" was very informative. I have a question about whether modifier -25 would work in the following scenario:A patient was previously seen for medial epicondylitis and was told that she would need a cortisone injection at her next visit if more conservative treatment failed. At the next visit, after the doctor determined the need for the cortisone injection, the patient received it. In this case, would you bill E&M code (99201-99203) with modifier -25, along with injection code 20550? If so, how would you justify it?

Question: Your article in the February issue of Physicians Practice about "better coding" was very informative. I have a question about whether modifier -25 would work in the following scenario:

A patient was previously seen for medial epicondylitis and was told that she would need a cortisone injection at her next visit if more conservative treatment failed. At the next visit, after the doctor determined the need for the cortisone injection, the patient received it. In this case, would you bill E&M code (99201-99203) with modifier -25, along with injection code 20550? If so, how would you justify it?

Answer: "An E&M service can be reported in addition to a procedure only if the patient's condition required a significant, separately identifiable service above and beyond that generally provided as part of the procedure," says Emily Hill. "CPT 2006 also clarifies that 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.'" In other words, your level of patient service must be supported by documentation supporting that the patient's condition warranted a significant and separate E&M service. In general, if this procedure was planned at a prior encounter, only the procedure code would be reported.

Procedures have some degree of E&M service associated with them; for example, providing verification of a patient's need for the procedure, giving explanation and consent, verifying allergies and other medical conditions that may impact the performance of the procedure, and observing the patient for the appropriate period of time following the procedure. Based on the scenario you describe, it doesn't appear that reporting an E&M service in addition to the knee injection would be in accordance with CPT guidelines.

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