E/M on Same Day as an Injection

Question:

My pain management physician saw a patient in the office and the chief complaint states that the patient is here for a trigger point injection (20552).  He has documented a detailed history, expanded problem focused examination and the decision making is low complexity since the patient is established and the pain is worsening.  Can I bill 99213-25 and the trigger point 20553 together?

Answer:

In order to report an E/M service with Modifier 25 on the same day as another procedure or service the service must be separately identifiable and goes above and beyond the preoperative work for the injection, an E/M can be reported if the patient’s condition required a significant E/M service on the day a procedure or service identified by a CPT code was performed.

• Above and beyond other service provided
• Beyond the usual preoperative and postoperative care associated with the procedure that was performed
• Different diagnosis is not required

However, based on the reason for the visit, “patient here for trigger point injection”, and the intent of the visit is the injection, the E/M service is included in the preoperative workup and not reported separately. Keep in mind there is an Inherent E/M service in every procedure.

*This response is based on the best information available as of 12/13/18.