Scenario 1 is the correct answer. Although documentation of both scenarios supports a Level 4 visit, only one supports the medical necessity to code an evaluation and management (E/M) visit on the same day with a procedure. Scenario 1 supports the need for a separate E/M visit, because a new problem was assessed and a treatment plan was established during the visit. The diagnosis of pain for the left knee is used because the rheumatologist has not made a definitive diagnosis of osteoarthritis and is waiting to confirm this with the radiology report.
For Scenario 2, there is no separate and/or significant identifiable reason for the E/M visit, so this does not support the medical necessity of a separate evaluation and management code. The patient was in the office for a second-round injection, and unless there was a separate examination of her RA or a change to her treatment, then an E/M visit for that date of service cannot be justified. Scenario 2 should be coded as CPT: 20611-LT, J7235; ICD-10: M17.5.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.