The problem here is the artificial nature of the billing rules, reimbursement, CPT set-up, how our time is valued etc.
Have I personally tried to talk/describe my way into how an injection is an E&M? Yes.
Is it right? Probably not. Dtrack is probably the most correct on this. The injection of a steroid is BEST described by the CPT code for an injection.
Also described by Dtrack - The CPT code includes a pre-op/E&M component that theoretically accounts for the time you spent describing the injection.
Is the reimbursement for an injection through Medicare adequate? Hells to the no. In fact, it wasn't adequate before they changed the RVUs on E&M codes. The RVU change to E&M visits accentuated the terrible reimbursement structure of the injection. They increased the value of E&M visits but they didn't increase the E&M value that is built into the CPT codes increasing the disparity between them.
Shouldn't you just bill an E&M to describe the factors you took into account ie. diabetes, hyperglycemia, blood thinner, CV risk, etc use along the with the injection. You are free to try if the significant, separate nature exists. We are supposed to use the 25 modifier, but its future is probably fraught. 25 is the difference in my opinion between money and no money and in certain areas it is simply 100% rejected outright with your practice having to contest every single case. I personally write 2 separate pargraphs and aim for separate diagnoses when I use it to try and show my thought process - and it sucks. Perhaps a local issue, but Aetna does everything they can to deny reimbursement for any injection + a follow-up visit. I recently did an STJ injection on a patient, reviewed their MRI with them, and planned an ankle scope. Aetna denied the visit. Wasn't the first time.
I personally often wonder if higher 25 use is more likely to lead to an audit. Like if 20550+99212 paid exactly the same as 99213 I feel like 99213 would be safer/less likely to result in a denial. 99212+ anything just seems like the easiest thing to deny. Its like they are saying - we know 99212 is supposed to be nothing.
I said this previously - Medicare created this "problem" with how they reimburse visits. Decent BCBS plans ie. PPO, federal, non-HMO plans reimburse in my area like $75-$80ish dollars for both E&M and injection. The difference is so trivial its not worth thinking about. By creating a $46 (something like that) difference they've really accentuated in our minds just how silly the whole thing is. How most follow-up visits where the patient is still in pain are mostly identical.
What's my devils's advocate response to all this. I suppose an impartial "industry podiatist" person on the other side would say - look, you hate the low $ follow-up visit but when it came down to it you were happy to cash in the injection on top of other services that were all really part of the same problem. ie. You did a 99203/73620 for instability and equinus and added the injection for plantar fasciitis to get yourself to $190-200ish, but that visit was really just a plantar fasciitis visit. Take the good with the bad.
I think we can survive this. Our real enemy is Medicare Advantage plans paying percentages of Medicare and private insurance that is racing to pay Medicare rates for surgery.
