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Oct 20th, 2017 - sschwartz 3 

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.

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Oct 24th, 2017 - ChrisW   39  1 

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

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Oct 24th, 2017 - sschwartz 3 

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.

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