E&M with Injections:  Two Diagnoses

E&M with Injections: Two Diagnoses

December 28, 2023

If we have an established patient where the physician evaluates the patient and decides to give an injection. The physician documents two diagnoses. May we report an E&M with the injection because we have two diagnoses?

An E&M is reportable with the injection when the significant separate service rules are met.   

Two answers apply: 

  1. We do not recommend reporting the E&M if the second diagnosis is at same location or joint that is being injected.  In this case, a second diagnosis does not meet the “separate service” part of the modifier 25 definition. 
  2. We recommend reporting the E&M-25 if the second diagnosis if: 
    1. The second diagnosis is in a separate anatomic location from the injection site, and 
    2. The second condition is evaluated and managed. 


*This response is based on the best information available as of 12/28/23.




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