When there is a separate E/M service
beyond the therapeutic injection, call on modifier 25.
Inflammation of tendons, joints, or bursa resulting in joint tenderness can be very painful. Often, patients experience pain or decreased motor function in the thumb and wrist. Therapeutic injection (direct insertion of a needle into the tendon or joint for medication administration and fluid aspiration) is performed to reduce pain and inflammation.
On the day of the injection procedure, a significant separately identifiable evaluation and management (E/M) service, above and beyond the injection, might also be performed. To ensure payment, append the E/M code with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Example No. 1
An established 57-year-old male presents to his physician with complaints of left wrist pain that he noticed four months ago. He has been taking over-the-counter pain reliever, which sometimes relieves the pain. The patient noticed swelling in the area two days ago.
Review of Systems:
Constitutional: No fever.
Respiratory: No cough or shortness of breath.
Cardiac: No chest pain.
Musculoskeletal: Swelling on the left wrist.
The physician reviews the past medical history, social history, medications, and allergies. No pertinent update.
Physical Examination: Vital signs: HT 5′ 6″, WT: 202 lbs
Patient appears to be healthy, well developed, well nourished, and in no acute distress. He is alert and well oriented x 3 with normal mood affect.
His skin is pink and well perfused.
Musculoskeletal Exam: Both left and right wrists are examined. Finkelstein test on the left wrist is positive for De Quervain tenosynovitis.
Assessment and Plan: The physician discusses the clinical impression with the patient. He also discusses the results of all diagnostic testing and the relevance to the current problem. The physician discusses treatment options, both non-operative and operative, including the benefits and risks of each. The patient and physician discuss options, and the patient wants an injection performed today.
Procedure: After informed consent is obtained, the patient is prepped and draped in a sterile fashion. The physician identifies the injection site by palpitation and marks the injection site. A 22-gauge needle is inserted medially, and a mixture of 1 cc of 1 percent lidocaine and 40 mg of kenalog-10 is injected into the tendon sheath. Patient tolerates the procedure well with no immediate complications. Physician recommends immobilizing the thumb and wrist with a splint or brace to help rest the tendons. Follow up is scheduled for six weeks.
99214-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity
20550-LT Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)-Left side
J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg x 4 units
Example No. 2
Patient is a 57-year-old male who presents for follow-up of evaluation of his left wrist pain. The physician evaluated him last time and discussed waiting six weeks before considering another injection if his pain did not subside. He improved in some capacity but has continued to have difficulty moving the thumb and wrist when doing something that involves grasping or pinching.
Review of Systems: No new injury or traumatic event.
Plan: The physician and patient had a lengthy discussion about options, and the patient wants another injection today.
Procedure: Informed consent is obtained, and the patient is prepped and draped in a sterile fashion. The physician identifies the injection site by palpitation and marks the injection site. A 22-gauge needle is inserted medially, and a mixture of 1 cc of 1 percent lidocaine and 40 mg of Kenalog-10 is injected into the tendon sheath.
Patient tolerates the procedure well, with no immediate complications.
20550-LT, J3301 x 4 units
On this follow-up visit, a significant separately identifiable E/M is not coded. There is minimal evaluation required before the procedure is performed.