Established Patient Encounter: Is Modifier 25 Supported?

Established Patient Encounter: Is Modifier 25 Supported?

November 16, 2023

Question:
An established patient presents to the office for return of knee pain six months after the last injection to the same knee. The patient relates no new injury and states that over the past few weeks, the pain has become unbearable. The physician evaluates the patient and decides to reinject the same knee. Does this meet the modifier 25 definition since the physician re-evaluates the patient?

Answer:
To report an E&M, the E&M must be the significant separate stand-alone service from the injection. In the scenario presented, the physician evaluated the knee in a prior encounter, and gave an injection that provided relief for about six months. There are no other complaints shared, no new injuries and no additional diagnostic tests, and the physician offers the same management option.

In this case, KZA does not recommend reporting an E&M with a modifier 25; the significant separate service rules are not met. Report the injection and medication administered.

*This response is based on the best information available as of 11/16/23.

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