Official Medical Fee Schedule: RVUs adjusted by county GPCIs, times a California conversion factor

• MTUS, presumed correct

• New York MTGs

Record the employer’s name and address, the date of injury, and the body parts and mechanism of injury in the patient’s words.

Confirm with the adjuster that the claim is open and which body parts are accepted; note the adjuster’s name, phone number and the date.

On a typical orthopedic clinic day, a patient with knee osteoarthritis, a painful shoulder or an arthritic hip is examined and receives a joint injection at the same visit. The billing question is whether that visit is a separately payable evaluation and management (E/M) service with modifier 25, or whether its payment is already built into the injection code.

The answer depends on Medicare’s global surgery rules, the note and each payer’s policy. It also carries compliance weight: same-day E/M billing with minor procedures has drawn Office of Inspector General (OIG) reviews since 2005, and CMS proposed a payment cut for these visits in July 2026. This guide covers the rules as of October 2026.

What do joint injection codes 20600–20611 cover?

CPT codes 20600 through 20611 describe drawing fluid out of a joint or bursa, injecting medication into it, or both, grouped by joint size and by whether ultrasound guidance is used:

Three billing details matter. Medicare’s fee schedule assigns 20610 a 0-day global period, which makes it a minor procedure. The NCCI Policy Manual counts one unit per joint, including its surrounding bursae, so aspirating a shoulder and two of its bursae is one unit of 20610. And for Medicare, the injection code does not include the drug other than local anesthetic; when your practice buys the drug, report it with its HCPCS Level II code.

Why is the decision to inject already paid for?

Every procedure on the Medicare Physician Fee Schedule has a global indicator. Procedures with a 0- or 10-day global period are minor procedures, and their payment covers the usual pre-procedure work, including the evaluation that leads to the procedure. That is the core of the global surgical package.

The NCCI Policy Manual (Chapter I, Section D, and Chapter IV, Section B, revised January 1, 2026) says the decision to perform a minor procedure is included in its payment and must not be reported as a separate E/M. The Medicare Claims Processing Manual adds that the initial evaluation is always included in a minor procedure’s allowance. Its example is a scalp laceration: a visit is billable if a full neurological exam is needed for head trauma, but not if the physician only decides sutures are needed and checks allergy and immunization status.

The decision to inject is part of the injection. A same-day E/M is billable only when the note documents significant, separately identifiable work beyond that decision.

Major procedures follow a different rule. An E/M on the day of or the day before a 90-day global surgery that results in the decision to operate is billed with modifier 57. Modifier 57 does not apply to injections or other 0- and 10-day procedures, and Medicare contractors do not pay it there.

What makes an E/M “significant and separately identifiable”?

Medicare pays a same-day E/M when the physician documents a significant, separately identifiable service above and beyond the procedure’s usual pre- and post-procedure work (Claims Processing Manual, Chapter 12, §30.6.6.B). NCCI frames it as an E/M unrelated to the decision to perform the procedure. On injection days, that usually means one of three things:

• A separate problem is evaluated and managed, such as new hip pain in a patient scheduled for a shoulder injection.

• A new or changed problem gets a real work-up: a differential diagnosis, imaging or labs ordered or reviewed, and a plan that goes beyond the injection.

• A management decision outside the injection is made, such as evaluating surgical candidacy, starting physical therapy or prescribing a brace.

Different diagnoses are not required; the E/M and the injection can share a diagnosis code when the E/M work is genuinely separate. AAPC’s advice is to document the two services separately and report the E/M only if it stands on its own.

Level the E/M on the separate work alone. The pre-injection assessment belongs to the injection, so it should not count toward medical decision making, and if you select the level by time, leave out the minutes spent on the procedure.

Does a new patient visit change the answer?

Medicare defines a new patient as one who has not received a face-to-face professional service from the physician, or a same-specialty physician in the same group, in the previous three years (Claims Processing Manual §30.6.7.A). New patients often arrive with undiagnosed problems, so their visits frequently include work beyond the injection decision.

Status alone does not justify an E/M, though. NCCI says being new is not enough by itself, and Medicare’s global rules bar billing the decision to perform the procedure for new and established patients alike. A patient referred to inject an already-diagnosed problem, with a brief assessment, usually supports the injection code alone.

When can you bill an E/M with a knee, shoulder or hip injection?

The table applies Medicare rules to common injection visits. Use it as a starting point; the chart decides each case.

The last row trips up many practices. CMS’s global surgery booklet calls for both modifiers 24 and 25 when a separately identifiable E/M on a procedure day falls within another procedure’s postoperative period, and Medicare denies a procedure with its own global period performed in that window unless it carries modifier 58, 78 or 79.

What documentation supports modifier 25?

Medicare does not require records with the claim, but both the E/M and the procedure must be documented well enough to support each service on review (Claims Processing Manual §30.6.6.B). A contractor that finds high modifier 25 use can review records case by case, educate the practice and then impose prepayment screens or documentation requirements. A defensible chart usually has:

• A distinct E/M section: the reason for the separate evaluation, pertinent history and exam, and the decision making for that problem.

• Evidence of work beyond the injection decision, such as a differential diagnosis, tests ordered or reviewed, and treatment other than the injection.

• A separate procedure note: joint and side, indication, consent, drug and dose, a saved ultrasound image when 20604, 20606 or 20611 is billed, and how the patient tolerated it.

• Diagnosis codes linked to the services they support.

• Patient-specific wording, not cloned text repeated at every visit.

When a payer bundles the E/M into the injection, the remittance often shows CARC CO-97, meaning the service’s payment is included in another service already processed. If the note shows separate work, appeal with the records. If not, the denial is correct and the fix is provider education. Our guide to common orthopedic claim denials covers other patterns.

Why is same-day E/M billing an audit focus?

OIG has examined same-day E/M billing with minor procedures for two decades:

• Its 2005 report Use of Modifier 25 (OEI-07-03-00470) found that 35% of modifier 25 claims Medicare allowed in 2002 did not meet program requirements, about $538 million in improper payments.

• A May 2025 audit of E/M services billed with eye injections (A-09-23-03014) found that documentation for 22 of 24 sampled services did not support modifier 25. CMS followed with a February 2026 MLN reminder that the decision to perform a minor procedure is part of the procedure.

• A November 2025 dermatology audit (A-04-21-04083) found that 90 of 100 sampled E/M services met requirements; OIG still recommended more oversight.

• In March 2026, OIG added a Work Plan review of E/M services paid on the same day as minor surgery without modifier 25, covering 2023–2025 claims (OAS-26-04-028).

The recent audits focused on eye injections and dermatology, but the rule they applied also governs 20610: the assessment that leads to a minor procedure is part of the procedure.

How do commercial payers handle modifier 25?

Commercial payers share the concept but differ on edits, records requests and payment. Policies we reviewed, as of October 2026:

Cigna twice announced, in 2022 and 2023, that it would require records with every E/M 99212–99215 billed with modifier 25 and a minor procedure, and delayed it both times. Other plans, including Aetna and other Blue plans, publish their own rules, and contracts can override policies, so confirm current versions before setting claim edits.

Can you add G2211 on an injection day?

HCPCS G2211, Medicare’s visit complexity add-on, is not paid when its office or outpatient E/M base code carries modifier 25, unless the other same-day service is an annual wellness visit, a vaccine administration or another Part B preventive service (CMS booklet MLN006764, May 2026). A joint injection is not one of those exceptions. CMS has also proposed replacing G2211 with a payment modifier for 2027, so recheck after the final rule.

What would the CY2027 proposal change?

In the CY2027 Physician Fee Schedule proposed rule (CMS-1848-P, released July 14, 2026; comments closed September 14, 2026), CMS proposed reducing payment when the same physician, or a physician in the same group practice, furnishes a separately identifiable office or outpatient E/M visit on the same day as a procedure with a 0-, 10- or 90-day global period. The higher-paid service would be paid at 100% and the other same-day services at 50%. CMS said it sees efficiencies when a visit and a global procedure happen together and that current payment is likely duplicative.

As of October 2026 this is a proposal, not a final policy. If finalized as proposed, it would apply from January 1, 2027, and the lower-paid of an E/M with modifier 25 and a 20610 would be paid at half. The coding rules above would not change: the E/M would still need to be significant and separately identifiable. See our CY2027 fee schedule overview for the rest of the proposed rule.

How Rette helps

Rette’s agents read the clinical and procedure notes in the EHR your practice already uses, such as athenahealth, Epic or eClinicalWorks, and suggest codes for your coders to review. They validate claims against NCCI, NCD and LCD rules before submission and bring related denials and appeals into one prioritized work queue.