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Timing considerations add complexity

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Fix: Only bill a separate E/M service when the documentation supports distinct medical decision-making beyond "patient here for injection." Dose adjustments, side effect management, and review of treatment progress all support a separate E/M service, but they must be documented

Using Modifier 25 for Office Visits If a patient comes in for a [sore throat] and, after an exam, the doctor decides they need a [Ceftriaxone] injection, you are doing two things: an [Evaluation and Management (E/M)] service and an injection

The formula is identical