The E/M visit would be coded as 99213 because both the history and the exam were at the expanded, problem-focused level. Even though the decision-making was of low complexity, the visit met the requirements for a level-three visit because this is an established patient and only two out of the three components are needed for a level-three code. Modifier -25 is added to identify a significant, separately identifiable E/M service provided on the same day of a procedure.
This office visit falls under incident-to billing but will be reimbursed at 100% of the allowable charges. Medicare incident-to billing guidelines are the same for all providers, regardless of specialty or whether the service was performed by another healthcare professional.
The joint injection would be coded as 20605-RT because the elbow is an intermediate joint. The -RT anatomical modifier is used to designate which elbow was injected. The drug Kenalog should be billed on the claim with HCPCS code J3301 with two units, because each unit is 10 mg.
