DecisionHealth, DecisionHealth - 2017 Issue 5 (May)

Add an E/M to this shoulder pain shot if it’s a new problem

Question: We had a patient present with shoulder pain and joint stiffness that had not been evaluated on a previous visit. Our physician examined his shoulder, discussed and documented various treatment options, and they mutually agreed on a shoulder injection. Can the physician bill for an E/M and the procedure with modifier 25 (Significant, separately identifiable E/M service) or just for the procedure alone?

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