tci Part B Insider - 2009 Issue 14

READER QUESTION: Check Documentation to Confirm Whether Modifier 25 Is Warranted

Nerve block includes minor evaluation and management service, so only bill an E/M if its significant and separately identifiable. Question: A new patient arrived with complaints of shoulder weakness and pain. My physician took a detailed history, performed a detailed exam, and did a diagnostic suprascapular nerve block to check for pain-causing nerve entrapment.Which codes are appropriate for this encounter? Answer: You should report the nerve block as 64418 (Injection,anesthetic agent; suprascapular nerve). Its likely that the office visit probably involved a low-complexity level of medical decision making (MDM). Provided that you have separate documentation that supports...

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