Coding Corner: Coding to support an injection procedure with a same-day E/M service

May 01, 2016
Area(s) of Interest: Emergency Services Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Oby Egbunikea, Manager of Professional Coding at Lahey Hospital and Medical Center, and G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

Under both CPT® and Centers for Medicare and Medicaid Services (CMS) guidelines, you may report an evaluation and management (E/M) service in addition to a minor procedure (such as an injection), only if: 


  • Documentation substantiates the medical necessity for, and performance, of a significant, separately-identifiable E/M service, and;
  • You report the appropriate E/M service code with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare provider on the same day of the procedure or other service appended.


Not every E/M is separate
All CPT® procedure codes include an E/M component: a brief patient history and physical, for instance, are inherent to any procedure. In practical terms, this means you should not report a separate E/M service on the same date as an injection (or other minor service)—even if the provider writes an assessment and plan—unless the patient has a new complaint or is experiencing a worsening of symptoms that prompts a new history, exam, and medical decision-making (which may include additional testing or therapy).


Example 1: The patient is a 57-year-old male who presents for follow-up of evaluation of pain in his left wrist. The physician evaluated him last time and discussed waiting six weeks before considering another injection if his pain did not subside. He improved in some capacity but has continued to have difficulty moving the thumb and wrist when doing something that involves grasping or pinching.


  • Review of Systems: No new injury or traumatic event.
  • Plan: The physician and patient had a lengthy discussion about options and patient would like another injection performed today.
  • Procedure: After informed consent was obtained, patient was prepped and draped in a sterile fashion. The physician identifies the injection site by palpitation and marks the injection site. A 22-gauge needle is inserted medially and a mixture of 1cc of 1 percent lidocaine and 40mg of kenalog-10 is injected into the tendon sheath. Patient tolerated the procedure well with no immediate complications.


  • 20550-LT Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar fascia)-Left side
  • J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg x 4 units


Because this is follow-up visit with no new patient complaint or complications, you may not report a significant separately identifiable E/M service. The injection is the only billable procedure.


Identifying separate E/M services
You should apply modifier 25 for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service,” per CMS Transmittal R954CP (Medlearn Matters Number: MM5025, Change Request 5025). To help you decide if an E/M service is truly “significant” and “separately identifiable” (and therefore separately reportable with modifier 25), ask yourself, “Can I quickly find in the documentation a clear history, exam and medical decision-making apart from any other procedures the provider performs on the same day?” If the answer is “Yes,” the E/M service is billable.


Example 2: An established, 57-year-old male presents to his physician with complaints of left wrist pain that he noticed four months ago. He has been taking over-the-counter pain reliever, which sometimes relieves the pain. The patient noticed swelling in the area two days ago.


Review of Systems:


  • Constitutional: No fever
  • Respiratory: No cough or shortness of breath
  • Cardiac: No chest pain
  • Musculoskeletal: Swelling on the left wrist
  • The physician reviews the past medical history, social history, medications and allergy, no pertinent update.

Physical Examination:


  • Vital Signs: HT 5 6”(1.676M), WT: 202IB (91.627) Kg, BMI 32.62Kg/m
  • Patient appeared to be healthy, well developed, well nourished and in no acute distress. He is alert and well oriented x 3 and in no apparent distress with normal mood affect.
  • His skin is pink and well perfused.


Musculoskeletal Exam: Both left and right wrist was examined. Finkelstein test on the left wrist positive for De Quervain tenosynovitis


Assessment and Plan: The physician discussed the clinical impression with the patient. He also discussed the results of all diagnostic testing and the relevance to the current problem. The physician discussed treatment options, both non-operative and operative including the benefits and risks of each. The patient and physician discussed options and the patient wants an injection performed today.


Procedure: After informed consent was obtained, patient was prepped and draped in a sterile fashion. The physician identifies the injection site by palpitation and marks the injection site. A 22-gauge needle is inserted medially and a mixture of 1cc of 1 percent lidocaine and 40mg of kenalog-10 is injected into the tendon sheath. Patient tolerated the procedure well with no immediate complications. Physician also recommended immobilizing the thumb and wrist, by keeping them straight with a splint or brace to help rest the tendons. Follow up was scheduled for six weeks.




  • 99214-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity
  • 20550-LT
  • J3301 x 4 units

In this case, the patient’s complaint of wrist swelling is new. The provider performs and documents a significant, separately identifiable E/M service, which leads to the decision to perform the injection. You may bill both the injection and the E/M service (with modifier 25 appended).


Document all diagnoses
The diagnoses underlying the E/M and the injection (or other minor procedure) may be the same, or different. Per Transmittal R954CP, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date” (emphasis added). When an E/M service leads to an unplanned, same-day procedure (as is the case in our second example, above), be sure that documentation substantiates that the decision to perform the procedure was made during the encounter. Per CMS Transmittal R954CP, you do not need to submit full documentation with your claim, but the documentation must be available upon request.


Counseling also may quality for separate E/M
Per CPT® guidelines, time—rather than history, exam and medical decision making—may become the controlling factor to qualify for a particular level of E/M services, “when counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility)…”


In such cases, you should use CPT® “reference times” to determine an appropriate E/M service level. Per CPT® guidelines, “When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used.” For example, a level 3 established patient outpatient visit (99213) has a reference time of 15 minutes, and a level 4 service (99214) has a reference time of 25 minutes. When reporting a time-based E/M service lasting 19 minutes, report 99213 because it has the closest reference time. When reporting a time-based E/M service separately with a minor procedure, be sure to append modifier 25 to the appropriate E/M service code.


Finally, be sure to document all pertinent information discussed during the session. For example, rather than enter into the medical record, “30 minutes of counseling,” the provider should summarize the content of the counseling or coordination of care. Best practice is to document the beginning and ending time of the counseling and/or coordination of care, and the beginning and ending time for the overall face-to-face visit.


Portions of this article previously appeared in AAPC’s Healthcare Business Monthly.



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