E&M with Injections: Two Diagnoses

Question:

When an established patient presents and the physician conducts an evaluation that results in the decision to administer an injection, with documentation of two distinct diagnoses, is it appropriate to report an evaluation and management (E&M) service in conjunction with the injection procedure based solely on the presence of two diagnoses?

Answer:

An evaluation and management service may be reported concurrently with an injection procedure when the criteria for a significant, separately identifiable service are satisfied.

Two answers apply:

1.      Reporting of the E&M service is not recommended when the secondary diagnosis pertains to the same anatomical location or joint that is the target of the injection procedure. In such circumstances, the presence of a secondary diagnosis does not fulfill the "separately identifiable service" requirement as defined by modifier 25.

2.      Reporting of the E&M service with modifier 25 is appropriate when:

a. The secondary diagnosis involves a separate anatomical location distinct from the injection site.

b. The secondary condition requires independent evaluation and management.