The proper way to code this visit is 99213-25, 20610, J3303x4, 73100, 715.16, 719.43.
Does this situation sound familiar? Your patient comes in on the day of a scheduled procedure and says, “Oh by the way ….” If your encounter turns from being a scheduled procedure into something more, you can bill Medicare for the E/M visit by adding modifier -25 to the E/M procedure code, if appropriate.
This visit should be billed as a mid-level E/M visit (99213-25: an expanded history and exam were performed on the patient because of his new diagnosis – wrist pain – with a medical decision making of low complexity), along with the following diagnosis codes:
- 20610: Major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa).
- J3303x4: Injection, triamcinolone hexacetonide, per 5 mg.
- 73100: Radiologic examination, wrist; two views (to determine fracture).
- 715.16: Osteoarthritis, localized, primary; lower leg.
- 719.43: Pain in joint; wrist.
Appropriate usage of modifier -25 is important. Remember to use modifier -25 on the E/M service only when billed with a scheduled procedure, and verify that the patient’s records clearly document that the E/M visit was a significant and separately identifiable service. Keep in mind that Medicare will bundle the E/M service with your procedure as inclusive if the modifier is not listed on the E/M code.