E&M with Injections:  Two Diagnoses

E&M with Injections: Two Diagnoses

December 28, 2023

Question:
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?

Answer:
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.

PREVIOUS ORTHOPAEDIC CODING COACHES

 

 

Sign up for KZAlertsSign up for KZAlerts

Coding Coaches