12/18/2019

Correct Billing for Subsequent Visit for Ankle Injection Prescribed NSAIDs (Prior visit-Injection in RT Ankle-Arthritis)

I have a patient whom I saw 4 months ago for arthritis right ankle. At that time, I gave her an injection. I saw her again yesterday with same chief complaint; only this time, the pain is worse than last time. I injected her ankle once more and will start her on NSAIDs. Dx code:M19.071. How is it billed? Can I bill 99212-25 modifier as the pain worsened and I am starting her on new medication?

The coding specified in the inquiry is correct- however, in order to bill the established patient office visit with modifier -25, the CPT code for the injection needs to be specified, along with any drugs (J-codes) used to manage the patients pain related to arthritis. Therefore, you can bill the office visit along with injection code and injectable.