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Injections and E/M Visits
How do you code for an unplanned injection as well as the E&M service necessary to make the decision to perform the injection?
Question:
How do you code for an unplanned injection as well as the E&M service necessary to make the decision to perform the injection?
Answer:
The answer to this question depends upon if you are providing a significant and separate evaluation and management service in addition to an injection, and not whether the injection was planned or unplanned. Every minor procedure has time for pre-service evaluation included in the value of the procedure code. Medicare and other payors have become concerned that E/M’s are being routinely reported with minor procedures without considering if the extent of the visit was truly more than the pre-service evaluation already included in the procedure. Just because an injection is unplanned does not automatically allow for an E/M visit to be billed. There must be a significant and separately identifiable E/M service above and beyond the injection. Please listen to our KZA KAST Modifier Monday podcast on Modifier 25 for additional information.
*This response is based on the best information available as of 11/20/25.
0232T
Hi. We would like a little guidance on what is included in the PRP code 0232T. If the PRP injection is rendered in a tendon and a tendon fenestration/tenotomy is performed, is the fenestration included in the PRP code? Also if PRP is being utilized to hydrodissect a tendon, is the hydrodissection included in the PRP injection?
Question:
Hi. We would like a little guidance on what is included in the PRP code 0232T. If the PRP injection is rendered in a tendon and a tendon fenestration/tenotomy is performed, is the fenestration included in the PRP code? Also, if PRP is being utilized to hydrodissect a tendon, is the hydrodissection included in the PRP injection?
Answer:
Thank you for asking KZA!
After creating platelet-rich plasma (PRP) from a patient’s blood sample, that solution is injected into the target area, such as an injured knee or a tendon. In some cases, the clinician may use ultrasound to guide the injection. The purpose is to promote and/or accelerate the healing process of the tendon and tissue regeneration.
Both fenestration and hydro-dissection are also performed to promote healing of the tendon and surrounding tissue, and when performed in conjunction with PRP injection, should not be reported separately.
*This response is based on the best information available as of 11/20/25.
63267 or 22102?
A patient presents with lumbar discitis and osteomyelitis, and the provider performs a laminectomy with debridement of the disc and bone. Which CPT code is more appropriate in this scenario: 63267 or 22102?
Question:
A patient presents with lumbar discitis and osteomyelitis, and the provider performs a laminectomy with debridement of the disc and bone. Which CPT code is more appropriate in this scenario: 63267 or 22102?
Answer:
Thank you for asking!
In this case, the procedure involves a lumbar laminectomy with debridement of both disc and bone due to infectious pathology. CPT code 63267 is the correct choice, as it describes a lumbar laminectomy for excision or evacuation of an extradural intraspinal lesion other than a neoplasm. Code 22102 applies to the partial excision of the posterior vertebral component, which does not accurately reflect the work performed.
*This response is based on the best information available as of 11/20/25.
Pediatric ENT Consultation
Our internal compliance team states that our pediatric otolaryngologists should never bill for a consultation. This is because the description in the 2025 CPT states "Services that constitute a transfer of care (i.e. are provided for the management of the patient's entire care or for the care of a specific condition or problem) are reported with the appropriate new or established patient codes." I have explained that when a pediatrician refers a patient to us for ear infections, we give our opinion on what treatment is needed, perform surgery and then send the patient back to the pediatrician. If the patient has another ear infection, we ask that they see their pediatrician for management of the acute infection. I argue that what we do does not constitute a "transfer of care". They suggested I reach out to KZA for clarification. Thank you!
Question:
Our internal compliance team states that our pediatric otolaryngologists should never bill for a consultation. This is because the description in the 2025 CPT states "Services that constitute a transfer of care (i.e. are provided for the management of the patient's entire care or for the care of a specific condition or problem) are reported with the appropriate new or established patient codes." I have explained that when a pediatrician refers a patient to us for ear infections, we give our opinion on what treatment is needed, perform surgery and then send the patient back to the pediatrician. If the patient has another ear infection, we ask that they see their pediatrician for management of the acute infection. I argue that what we do does not constitute a "transfer of care". They suggested I reach out to KZA for clarification. Thank you!
Answer:
CPT 2025 has removed previous language related to "transfer of care" from the consultation code section. Most payors no long accept consultation codes and require you to use problem-oriented E/M codes, but there still a few payors who pay for consults. CPT now emphasizes that consultation codes can be used when the criteria for a consult are met, regardless of whether the patient is new or established.
According to CPT, a consultation is appropriate when:
A physician requests another physician’s opinion or advice regarding diagnosis or treatment.
The consulting physician provides that opinion and communicates back to the requesting physician.
The consulting physician does not assume ongoing care for the condition.
The pediatrician refers the patient for evaluation and possible surgical treatment in your case. Your team provides an expert opinion, performs the surgery, and then returns the patient to the pediatrician for ongoing care. You do not manage the patient’s long-term treatment for recurrent infections. This aligns with the definition of a consultation rather than a transfer of care. The fact that you send the patient back to the referring provider and do not assume continuous management supports your use of consult codes. It is important to check with your individual payor to determine if they accept consultation codes or if they require problem-oriented E/M codes.
*This response is based on the best information available as of 11/20/25.
E/M During Global Period for Diabetic Foot Ulcer Following Total Metatarsal Amputation
If a patient has a total metatarsal amputation for diabetic foot ulcer and he gets readmitted for another condition, but then vascular surgery is consulted for his original underlying condition of DFA and now is treating the ulcer at the amputation site, 80 days post-op is the E/M billable? The TMA surgical wound is healing . The right plantar DFU stage 3 Wagner needs debridement and dressing changes.
Question:
If a patient has a total metatarsal amputation for diabetic foot ulcer and he gets readmitted for another condition, but then vascular surgery is consulted for his original underlying condition of DFA and now is treating the ulcer at the amputation site, 80 days post-op is the E/M billable? The TMA surgical wound is healing. The right plantar DFU stage 3 Wagner needs debridement and dressing changes.
Answer:
The evaluation and management service is not separately billable because it appears to represent continued management of the same surgical and disease process that prompted the original total metatarsal amputation. Any care directed toward the amputation wound or related diabetic ulceration in the same region during the 90-day global is included in the global period.
*This response is based on the best information available as of 11/20/25.
CPT 44130 “Separate Procedure” Designation
CPT 48150 describes a pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy, with pancreatojejunostomy. CPT 44130 describes an enteroenterostomy, an anastomosis of the intestine, with or without cutaneous enterostomy, and is designated by CPT as a “separate procedure.”
According to NCCI edits, there is a procedure-to-procedure (PTP) conflict between 44130 and 48150 when performed during the same encounter, which can be bypassed with modifier 59. If a provider routinely performs an enteroenterostomy in conjunction with the Whipple procedure to prevent future bile reflux—a common postoperative complication—is it appropriate to append modifier 59 to 44130?
Given that these procedures are frequently performed together, could the enteroenterostomy be considered an integral component of the Whipple procedure, rather than a distinct, independent, or unrelated service? While the Whipple procedure description does not specifically include an enteroenterostomy, it does involve bile redirection via choledochoenterostomy. The enteroenterostomy similarly aids in bile flow redirection, serving as an additional step to reduce bile reflux.
In light of this, should these procedures be routinely unbundled and billed together?
Question:
CPT 48150 describes a pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy, and gastrojejunostomy, with pancreatojejunostomy. CPT 44130 describes an enteroenterostomy, an anastomosis of the intestine, with or without cutaneous enterostomy, and is designated by CPT as a “separate procedure.”
According to NCCI edits, there is a procedure-to-procedure (PTP) conflict between 44130 and 48150 when performed during the same encounter, which can be bypassed with modifier 59. If a provider routinely performs an enteroenterostomy in conjunction with the Whipple procedure to prevent future bile reflux—a common postoperative complication—is it appropriate to append modifier 59 to 44130?
Given that these procedures are frequently performed together, could the enteroenterostomy be considered an integral component of the Whipple procedure, rather than a distinct, independent, or unrelated service? While the Whipple procedure description does not specifically include an enteroenterostomy, it does involve bile redirection via choledochoenterostomy. The enteroenterostomy similarly aids in bile flow redirection, serving as an additional step to reduce bile reflux.
In light of this, should these procedures be routinely unbundled and billed together?
Answer:
While modifier 59 can technically be used to bypass the NCCI edit between CPT 44130 and CPT 48150, it is not generally appropriate to routinely unbundle and report these codes together.
According to Medicare NCCI guidelines and CPT principles regarding “separate procedures,” CPT 44130 should only be reported when it is performed independently or is clearly distinct from other procedures. In the context of a Whipple procedure (CPT 48150), the enteroenterostomy is typically considered an integral part of the overall surgical approach, especially when performed to prevent bile reflux—a known complication.
CPT 48150 is the Column 1 (comprehensive) code, and CPT 44130 is the Column 2 (component) code. The “separate procedure” designation for 44130 indicates that it should not be reported in conjunction with a more extensive procedure unless it is truly separate and unrelated.
Therefore, unless there is clear documentation that the enteroenterostomy was performed for a distinct reason unrelated to the Whipple procedure, routinely appending modifier 59 to report both codes together would not align with coding guidelines.
*This response is based on the best information available as of 11/20/25.
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