Repeat Injections, Can I bill an E/M?

When reporting an office visit in conjunction with an injections/arthrocentesis we need to consider a few factors. First we need to be certain we are accurately applying modifier -25 which is required when a procedure is performed the same day as a procedure. In order to report modifier -25, the service should be significant and separately identifiable; above and beyond the usual preoperative and postoperative care associated with the procedure. In 2002, OIG conducted an audit randomly selecting 450 claims and it was discovered that thirty-five percent of claims using modifier 25 did not meet the program requirements resulting in $538 million in improper payments . 

·         Documentation supports a significant and separately identifiable E/M services was provided on the same day as the procedure.

·         E/M is medically necessary and supported via documentation; with the appropriate key components i.e. history, exam, and medical decision making.

·         Documentation does not support the E/M service.

·         Services are not medically necessary.

Reminders:

§ Be very careful when reporting an E/M with a procedure when it is a repeat or planned procedure. Typically, services of this nature do not meet the requirement to append modifier -25 in that the service is not significant or separately identifiable; over and above what is typical pre and post procedure work.

§ A separate diagnosis is NOT necessary when reporting an E/M with a procedure on the same day.

§ Avoid routinely reporting an E/M; just because a patient enters the office, an office visit may not necessarily be reportable or medically necessary.

§ Be mindful of existing global period you may need to append both modifiers -24 & -25 to the E/M service along with modifier -79 on the procedure.

§ Modifier-25 has been targeted by the Office of Inspector General for over-utilization under a special fraud alert.

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