E/M service with treatment of Psoriasis

Question:

A new patient came in with an itchy scalp and came into my office today with a flare-up of her psoriasis.  Her psoriasis was diagnosed by another physician about 6 months ago. The psoriasis is worsening in her hand, but her scalp is fairly clear.  She has been using over-the-counter medication, which has not helped.  After a lengthy discussion about her condition, we decided a steroid injection on her palm would be beneficial since her entire palm was covered with scaly patches. I performed an injection on her hand and reported 11900 (intralesional injection).  I also wrote her a prescription for a topical ointment and scalp oil to use when needed.  We also discussed light box treatment, but she wants to try a topical prescription.  My question is can I bill an E/M service with the procedure?  One of my other colleagues told me I could not.

Answer:

Since you are doing more than the evaluation for the injection (11900), yes, you can bill an E/M service.  There is an inherent E/M service included in every procedure, but you counseled the patient, offered alternative treatment options, and prescribed prescription drug medications to the patient.  In this instance, the service does qualify for a significant separately identifiable E/M service with Modifier 25.  Based on the complexity of the problem addressed, which is chronic and not at treatment goal, and you prescribed prescription drug medication, you should report CPT codes 99204-25, 11901 and the J code for the medication injected.

*This response is based on the best information available as of 9/11/24.