We regularly invite you to submit questions about what you read in Coffee & Coding or any coding-related issues you may encounter. This week, we’ll answer a few questions we’ve received.

  1. Why can’t vaccinations and therapeutic injections be counted toward the MDM (medical decision-making) portion of an E/M?
    • These procedures are billed independently with their own CPT codes. You should add to the E/M documentation anything with a “J” code for drugs, vaccination drugs covered by your state, or the injections themselves (90471/90472/96372).
  1. Why can’t an office visit be charged if the patient came in only for a vaccination? Shouldn’t an RN charge be included?
    • No, because the visit was scheduled just for that 5-minute vaccination appointment.
  1. Can we include an office charge if the doctor performs a joint aspiration or injection? Is there an exception to this?
    • Again, the answer is no, regardless of the procedure. If the appointment was scheduled purely for a joint aspiration or injection, it does not count as an office visit. But there is an exception to the rule. Let’s say your patient arrives for a knee injection and mentions they have been experiencing pain in their wrist. In this case, an additional charge for an office visit is warranted because you addressed a new issue unrelated to the knee.
  1. If the doctor directs the patient to the emergency room for treatment, is that billable as high in the risk category for MDM?
    • Yes, but only in certain situations. Here are a couple of scenarios that would qualify as high for risk:
      • The provider performs what is commonly called a “warm handoff”—calling ahead to the ED/ER and documenting (a) their medical concerns about the patient; (b) the reason for the referral to the emergency department; and (c) the name of the person at the ER who fielded the call.
      • If the patient needs to be stabilized before or after the call for an ambulance, and the physician is with and constantly monitoring the patient, you could bill the encounter at the high risk level. Even so, because of the physician’s continued presence, we suggest billing by time for a case like this.


We at Calm Waters AI wish you all a happy and relaxing Fourth of July holiday!


Download PDF

Michelle Sergei-Casiano
Michelle Sergei-Casiano
Michelle Sergei-Casiano
Senior Manager, Regulatory and Coding Compliance