Billing f/u visit and injection same day

[clubdeac]

Here's a dumb question from a guy starting out in the real world. Patient comes into your office for either a f/u visit or new patient visit for his axial lbp. During the interview he mentions he has knee pain and would like an injection. Can you do the injection at that visit and get reimbursed the full amount for the large joint injection or do you have to schedule that another day to get the full reimbursement?

Same scenario but he comes in for f/u of his chronic knee pain that you have been treating. He says the last injection you did 4 mos ago has worn off and I would like another. Again, can you bill for the office visit and the injection or do you have to reschedule the injection to get "properly" reimbursed?

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[Ducttape]

from talking to the hospital billers... for scenario 1, you can do the injection at that visit, and discuss his chronic pain condition, and use a 25 modifier. it may be less money, but the advantage is that you are not using a whole appointment slot later for the knee injection, and can book him for something else, like a LESI.

if he is a new patient, tho, some insurances will not allow you to do a procedure on a non-established (i.e. first visit) patient, unless there are extenuating circumstances.

if he comes in for follow up on his knee pain and would like another injection, technically i have been told you cannot use the 25 modifier to discuss his pain and do another injection. just bill for the injection. but you can use the 25 modifier to talk about the side effects and monitor his use of antiinflammatory medications and do the knee injection. 2 separate codes = can use 25 modifier.

 

[NOSfan]

See this:

http://www.aaos.org/news/aaosnow/oct09/managing1.asp

 

[bedrock]

Our billing folks have showed us new clarifications from CMS this year that you basically can't bill office visits and injections on the same day. Even if there is a different service provided under the office visit.

Now in our practice, medicare and medicaid never get same-day injections, (Peripheral or spine).
Still doing them sometimes for patients with commercial insurance.

 

[emd123]

Our billing folks have showed us new clarifications from CMS this year that you basically can't bill office visits and injections on the same day. Even if there is a different service provided under the office visit.

Now in our practice, medicare and medicaid never get same-day injections, (Peripheral or spine).
Still doing them sometimes for patients with commercial insurance.

Really? Can you post a link to that?

 

[Finally M3]

Our billing folks have showed us new clarifications from CMS this year that you basically can't bill office visits and injections on the same day. Even if there is a different service provided under the office visit.

Now in our practice, medicare and medicaid never get same-day injections, (Peripheral or spine).
Still doing them sometimes for patients with commercial insurance.

Would like the link for this as well, because of as of this year, the billing course we were forced to do stated that as long as the patient isn't in the office just for the injection (established patient, sporadic knee injections, wants another) and you clearly state in the medical management portion that injection is one option out of multiple options (meds, therapy, etc), then you can bill both for E&M and injection.

 

[emd123]

Would like the link for this as well, because of as of this year, the billing course we were forced to do stated that as long as the patient isn't in the office just for the injection (established patient, sporadic knee injections, wants another) and you clearly state in the medical management portion that injection is one option out of multiple options (meds, therapy, etc), then you can bill both for E&M and injection.

+1

Just checked with my billing people and they echoed the same thing, that there haven't been any changes that they're aware of. That being said you have to document you did something other than the procedure, ie, wrote rx, discussed MRI, sent UDS, or something unrelated to the procedure, and that you examined them and took the require history for the e&m level, ie, separate note.

 

[bedrock]

No link that I'm aware off. I'd try to scan a copy of the document.

 

[NEA]

I have had a bunch of denials when using the f/u codes along with procedures. I have now resorted to just billing for the procedure itself and taking a hit on the f/u visit.

 

[PinchandBurn]

I have had a bunch of denials when using the f/u codes along with procedures. I have now resorted to just billing for the procedure itself and taking a hit on the f/u visit.

Why is that? Arent you guys using a 25 modifier?

I've just heard you dont want to use it all the time, but as long as its used appropriately and intermittently....

 

[lobelsteve]

My patients have caught on to this and book procedures instead of follow-ups. Same co-pay and they get refills at time of procedure.

I've got a few patients that have had 6 months of care with only a consult and the rest procedure visits.

My follow up visits were down 250 from last year but revenue up 12% because of patients shifting to procedures from OV. This just means less work and more charges per visit. I guess there is a little more money for less work, but not as satisfying without knowing what I am doing is helping from a functional standpoint (I like hearing what hey are doing with less pain while at work or with hobbies).

 

[SSdoc33]

My patients have caught on to this and book procedures instead of follow-ups. Same co-pay and they get refills at time of procedure.

I've got a few patients that have had 6 months of care with only a consult and the rest procedure visits.

My follow up visits were down 250 from last year but revenue up 12% because of patients shifting to procedures from OV. This just means less work and more charges per visit. I guess there is a little more money for less work, but not as satisfying without knowing what I am doing is helping from a functional standpoint (I like hearing what hey are doing with less pain while at work or with hobbies).

I'll see the patients I know very well for the injection and f/u on the same day. Like the LOL with stenosis that gets a shot around every 4 months

 

[Ducttape]

I'll see the patients I know very well for the injection and f/u on the same day. Like the LOL with stenosis that gets a shot around every 4 months

ive talked to the billers multiple times about this.

in order to "justify" the injection, i do a follow up that will not be billed - its purpose is to make sure that the injection is indicated and is part of the payment for the injection.

i will then have a "separate" discussion that is clearly billable and a separate component. for example, a discussion on the side effects and potential complications of antiinflammatory agents. a review of opioid risks, including benefits, ODI, side effects, urine tox screens, all that we discuss, and i bill this under the cpt code for Long term use of opioid analgesics (V58.69). i have a preprogrammed smartphrase: "I spent *** minutes out of *** total appointment time discussing *** management, including ***". (i stopped using code 304.00.)

i have not had denials thus far.


The problem now is with a couple of insurance companies, particularly one with an oxymoronic name, is now demanding a follow up appointment to assess treatment efficacy before allowing further injections. it is a "managed" Medicaid program...

 

[bedrock]

The solution is to drop that Medicaid program. They can't pull that crap when they pay less than half of commercial insurance rates

 

[PinchandBurn]

The solution is to drop that Medicaid program. They can't pull that crap when they pay less than half of commercial insurance rates

True. But I mean its more revenue for you. And justifiable cuz we can tell them tht their insurance is mandating th t extra visit....

 

[specepic]

it really comes down to:

- was the decision to do the injection made at a previous visit or made that day?

- even if decision made prior to do the injection (e.g. seeing pt for euflexxa 2 of 3 R knee) but they present you with a new seperate issue: "hey doc my low back bothers me", and you eval and treat that then that would be a seperate code

This applies to injections, and in my case, OMT as well. Chiros for example, and PTs, often set up treatment plans where they decide at an initial visit to do manual therapy for x visits. They therefore will only bill porcedure codes for those

When I am in clinic it is RARE that I bill a procedure code only unless a knee euflexxa series and even then if we discuss their cymbalta, or their shoulder, wham, -25.

Please do not be whimpy and sell yourself short. Bill for the work you do. you did a lot of training and have earned every penny you bill

The only time I bill procedures only is on fluoro days, I almost never fluoro same day and if I do it is urgent and then I damn well -25 for the eval done earlier that day in clinic given the MDM

 

[clubdeac]

Ok one more variation to this question. Let's assume you are addressing two separate issues in the office visit, knee pain and cervical radiculopathy. Let's say you decide to add modifier -25 and do an injection. Is there any difference in the likelihood of getting paid for both the office visit and the procedure if you do a CESI vs a knee injection. In other words, does the type of procedure you add on matter?

 

[Ducttape]

some insurance companies are now not allowing different injections to be done on the same day (ie CESI and knee injection), barring a specific reason such as anticoagulation. (no change to billing 99214 + injection...)

 

[emd123]

If you bill an E&M and add a procedure (-25) you should be fine adding one procedure as long as you did something other than the procedure to justify your office visit E&M like write an Rx, do an exam, etc.

I don't it matters which procedure you add to an E&M, as long as you don't get greedy and try to add a second, third, etc (unless special situation/anticoagulation held, etc). You must have a procedure note to bill the procedure and an exam/history note to bill the EM also.

The only glitch in getting a "bigger" procedure paid for would be if it needs a Prior auth. Small potato stuff (tpi, joint) almost never do so you can add that on the fly, whereas TFs, MBB, or rf might need a PA so it's sometimes needed to delay just to get auth. If you have someone get it auth'd right away (or doesn't need one, ie, Medicare) then you can easily add that same day on the fly.

Does that answer your question?

 

[clubdeac]

Perfect, thanks emd!