E&M and Injections: Is this billable?

Question:

We have a new patient presenting for evaluation of new elbow pain following a fall.  The provider documented a full history, exam, ordered and interpreted X-Rays.  Following this evaluation and discussion with the patient, they agreed the best option was to aspirate and inject the joint.  The procedure note documents the aspiration and injection of a corticosteroid. Does this meet the significant, separate service rules to report both the E&M and the aspiration/injection?  

Answer:

Based on the description of the encounter, KZA recommends reporting the E&M-25 and the injection code (20605) and the J code for the drug.  Remember, Medicare requires the JW or JZ modifiers effective July 1, 2023, if the medication was obtained from single-dose package.   Review with your private payors if they are following the same requirement.   

Rationale:  

New problem  

The intent of the visit was not the injection.  

Full E&M service performed.  

Joint decision making with patient on options and to proceed with minor procedure.  

*This response is based on the best information available as of 1/30/25.