November 2, 2023
We have a new patient presenting for evaluation of new elbow pain after a fall. The provider documented a full history and exam then ordered and interpreted x-rays. Following this evaluation and discussion with the patient, they agreed the best option was to aspirate and inject the joint. The procedure note documents the aspiration and injection of a corticosteroid. Does this meet the significant, separate service rules to report both the E&M and the aspiration/injection were met?
Based on the description of the encounter, KZA recommends reporting the E&M with modifier 25, the injection code (20605).
You may also report the J code for the drug (with the appropriate units) if you are in place of service 11 (physician office). Remember, Medicare requires the JW (drug wasted) or JZ (no drug wasted) modifiers effective July 1, 2023, if the medication was obtained from single-dose package. Review your private payor policies to determine if they follow the same requirement.
Our rationale for allowing both the new patient E/M with modifier 25 and the injection code is as follows:
1. This is a new problem,
2. The intent of the visit was not the injection,
3. A full E/M service performed, and
4. There was joint decision making with patient on options and to proceed with the minor procedure.
*This response is based on the best information available as of 11/2/23.