by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
August 19th, 2015
But increasingly, payers are being just as reflexive when it comes to denying the E/M service, saying that it's bundled into the injection.
What's the truth? While there are many instances when the E/M service is bundled into the injection service, there are probably just as many instances when these denials can and should be successfully appealed, based on additional treatments or services being rendered during the visit.
For purposes of this article, we'll focus on common musculoskeletal injections, such as those in the 20500-20612 code range. CPT guidelines do not allow these minor procedures to be billed on the same date of service as an E/M service unless the E/M service is for a significant, separately identifiable reason.
When there is a significant, separately identifiable E/M service provided, it can be billed with the appropriate E/M code, appended with modifier 25 (significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service).
It is up to the payer to set the rules for when it is appropriate to use modifier 25 for the E/M service, in order to justify whether both the procedure and E/M code are separately payable for that encounter.
Medicare defines these injection codes as minor surgical procedures and assigns zero global days to these codes. This means that, according to Medicare's National Correct Coding Initiative (NCCI) edits, the typical pre- and post-service work associated with the injection are considered to be part of the payment for the injection itself. In this scenario, this work does not rise to the significant, separately identifiable level of service that would justify the use of modifier 25 on a separate E/M claim.
As further noted in Chapter 1 of Medicare's NCCI manual, "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.
However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses."
While the NCCI edits typically list established patient E/M services as bundled into these injection codes, the NCCI manual states that the same rules for minor procedures also apply to new patient encounters. Many private payers follow NCCI rules, but you will need to verify with each payer that you are following its specific rules for billing an E/M on the same date as an injection.
The most common instance where an E/M would not be separately payable is when the patient presents for a scheduled injection that arose from a prior E/M service.
Consider these two common examples where the E/M would likely not be supported for separate payment:
1. Injection arises from earlier E/M visit. A patient presents for an E/M service and the provider says that if the treatments don't work, then the patient should return for an injection. If the patient then returns for a separate visit for an injection, and the documentation
reflects no additional medical decision making beyond the typical pre- and post-service work, then a separate E/M visit would likely not be supported.
2. Visit is for a scheduled injection. A patient is coming in for visits for a series of scheduled injections. In this case there isn't enough justification for a separate E/M service if the patient simply visits, has the affected area checked out, and receives the scheduled injection.
When you can support a separate E/M
Typically, you can justify a separate E/M visit in two ways.
First and this is the easiest way - if the patient has a separate injury or problem addressed by the provider and documented in the medical record, then the treatment of that issue supports a separate E/M service.
Some Medicare Administrative Contractors (MACs) make it clear that they allow a separate E/M service for the visit or encounter when the patient begins the series of injections and the documentation supports the E/M service billed.
The second option is more difficult, but it involves justifying the separate E/M service with documentation of a diagnostic process that results in the decision to administer an injection. Documentation of an evaluation of the problem area, or the use of X-ray services, can help support the case that the separate evaluation was necessary, and the result of the evaluation was the decision to move forward with an injection.
Separate treatment of the injury, such as medical decision making to write a prescription or advise lifestyle modifications, can also serve as proof that the encounter involved more than just the injection.