E&M with CPT 20610

Our Orthopedic provider will see a patient for , let's say LT knee pain. He will then also do a large joint injection 20610 on that knee as well. He then insists I am to bill an E&M 99214 and use ICD10 for LT knee pain with modifier 25 and also bill 20610 for Unilateral primary osteoarthritis, left knee. I am uneasy about this as the knee pain is a result of the arthritis. I had been told that only bill both if it was a new patient visit, and any follow up visits for the knee that required a large joint injection, I was to only bill the 20610 and of course the j1030 which he normally uses. He insists I am to bill both always, and even if he only has the current medical condition as osteoarthris of the knee, he request I add the pain code for the E&M he has also charged. Is he correct or is he trying to unbundle in a way he should not? I understand if he saw someone for maybe both knees and only injected one of them, or a shoulder and knee; using both the E&M and the 20610, but am really worried that what he is insisting is wrong and unethical billing.

Visit on day of procedure is generally not payable as a separate service

Due to the fact that most payers follow CMS guidelines, I will be referring to CMS and the information found on Find-A-Code.
20610 - Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance has -0- global days- 000 - Endoscopic or Minor Procedure.

0-Day Post-operative Period (endoscopies and some minor procedures)
• No pre-operative period
• No post-operative days
• Visit on day of procedure is generally not payable as a separate service

CMS Guidelines:
Minor Surgeries and Endoscopies: Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.

If the E/M was significant and separately identifiable, you could bill the E/M with a 25 modifier.

Here are a few articles that may help you. MLN Global Surgery Booklet
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Also refer to the “Medicare Claims Processing Manual”, Chapter 12, Sections 40 and 40.1

E&M with CPT 20610

The website you gave for the MLN Global surgery Booklet didn't take me to it, said an error. Could you re-send me that link? My main concern is if Knee pain would be considered a separately identifiable issue with the Knee Arthritis the Provider uses for the 20610. To me it doesn't seem so but he insists I bill knee pain to the 99214 and arthritis of knee with the 20610.

Knee injection

I agree sschartwz
If your doc has previously seen this patient and diagnosed him with OA
This visit he should be only billing for the injection procedure and should not charge for the Office visit.
He did not do anything new this visit.
He already knew what the patients diagbpsus was

It’s a common thing. Everybody bills 99313,99214 on patient who are well known and already diagnosed and coming back for repeat injection

Knee injection

I agree sschartwz
If your doc has previously seen this patient and diagnosed him with OA
This visit he should be only billing for the injection procedure and should not charge for the Office visit.
He did not do anything new this visit.
He already knew what the patients diagbpsus was

It’s a common thing. Everybody bills 99313,99214 on patient who are well known and already diagnosed and coming back for repeat injection