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.

Intracranial Endovascular Venous Thrombectomy

Question:

How is an Intracranial endovascular venous thrombectomy coded?

Answer:

There are no intracranial venous endovascular codes, so this must be reported as an unlisted code, 64999.  If performed and documented, a venogram, and the venous catheterization may also be reported.

*This response is based on the best information available as of 12/28/23.

Procedure Coding

Question:

What is the difference between a biopsy and removal when it comes to dermatology.

Answer:

A biopsy is a sample of a suspicious lesion on the body and the tissue is sent to a laboratory for testing. Where shave excisions are removals of lesions without taking the full thickness of the skin. These codes include local anesthesia. The wounds do not require suture closure.

*This response is based on the best information available as of 12/28/23.

E&M With Injection: What If We Want to Code Based on Time?

Question:

We have a recent case where a patient returned with return of pain about five months after a previous injection. The physician evaluates the patient noting no new injury, no changes in his exam findings and decides to re-inject the patient’s knee without additional treatment options discussed. We shared with the physician that the E&M was not separately reportable. The physician asked, ‘what if I code based on time, is it reportable then?” We are unsure if this makes a difference or not. Will you address this question?

Answer:

KZA agrees with your initial recommendation based on the information provided. In terms of your specific question, whether the rules associated with modifier 25 (significant, separate service) vary based on the methodology supporting a level of service, the answer is “no”.

The E&M guidelines address how to select a level of service based on either MDM (Medical Decision Making) or Time. The rules associated with modifier 25 are specific to the E&M meeting the significant separate service rules, not the methodology of E&M code selection. In the scenario provided, the significant separate services rules are not met; report the injection and drugs, as appropriate.

Cholecystotomy Procedure

Question:

How should you code an open cholecystotomy, with a drain placement and a biopsy of the gallbladder wall is performed. Can the biopsy of the gallbladder be separately reported?

Answer:

No, the biopsy of the gallbladder wall is not separately reportable this is bundled and inclusive to the cholectstotomy. The correct code to report for this procedure would be CPT 47480,Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure).

*This response is based on the best information available as of 12/14/23.

E/M Coding for Emergency Surgery

Question:

Under the revised 2023 EM guidelines what E/M code would be supported for seeing a patient in the the ED for a ruptured cerebral aneurysm and taking them emergently to surgery for repair?

Answer:

This scenario would support , 99223, the highest level of Initial hospital care. Based on:

• High Problem-Acute or chronic illness or injury that poses a threat to life or bodily function and,
• High Risk- Emergency surgery

Remember, only 2 of the 3 medical decision-making elements are needed to support a level of E/M.

*This response is based on the best information available as of 12/14/23.