Established Patient: New Injury and Injection

Question:

We have a major hip and knee practice. We frequently see patients back for repeat injections; typically, we do not report the E&M, and report the injection only.

Recently, in one of our coding meetings, we discussed “well, what if the patient presents with a new injury and the physician re-injects the same joint.”

The scenario the team created was as follows:

Established patient, prior knee injections, presents for unplanned visit with a new twisting injury sustained when the patient tripped over a rock while trail hiking. The injury caused the patient to lose balance and fall into a tree. The patient presents with complaints of the twisting injury, knee swelling and bruising in the area. The physician will order X-Rays. After reviewing the physician aspirates and injects the joint.

Does this meet modifier 25? We have not typically billed for this type of encounter and are trying to decide if we\ are too conservative in our approach.

Answer:

KZA appreciates the coding team meeting to discuss issues, concern about accurately reporting modifier 25 or not, and the detailed scenario.

KZA recommends reporting the E&M and an aspiration/injection in your scenario. There is a new injury requiring the physician to perform a medically appropriate exam and the decision to order X-Rays. The work is not related to a “repeat” injection but is medically necessary to evaluate the new injury. The physician will have an injury diagnosis, possible effusion diagnosis since an aspiration was performed and the diagnosis for any underlying condition if the fall caused an exacerbation of the underlying condition.