Procedure with E&M

Can anyone provide clarification on when it is appropriate to bill an e/m with a minor procedure done in the office?

For example:

Patient presents with shoulder pain and joint stiffness and has NOT been evaluated on a previous visit. Physician examines the shoulder, discusses and documents various treatment options, risks and benefits of each and then the decision is made for an injection into the shoulder.

Would the scenario above be considered separately identifiable?

Comments

  • I would bill the e/m because the patient hadn't been evaluated for the shoulder at a previous visit. Insurance might say something different. We have had brand new patients where we did a full work up and ended up doing an injection and insurance wouldn't pay for the new patient e/m stating it is included in the injection.


  • I agree with Renee but you must have modifier -25 attached to the E&M as
    well as a different diagnosis from the diagnosis on the injection. In other
    words, use pain dx for the E&M and the actual problem (i.e. osteoarthritis,
    adhesive capsulitis, etc.) dx for the injection.



    Maryann Cross

    Certified Coding/Billing Specialist

    Central Carolina Orthopaedic Associates

    1139 Carthage St., Ste 101

    Sanford, NC 27330

    919-774-1355

    919-775-1644 (fax)




  • Disagree about different diagnoses. First, the official ICD-10 coding guidelines state do not code symptoms once a definitive diagnosis is made and second, use of different diagnoses is not required to use modifier -25.

    “Significant, separately identifiable E&M service by the same physician on the same day of a procedure or other service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E&M Service may be prompted by the symptom or condition for which the procedure was provided. As such, different diagnoses are not required for reporting the E&M services on the same date. The circumstance may be reported by adding modifier 25 to the appropriate level of E&M service.”

    From: Mary Ann Cross [mailto:mcross@centralcarolinaortho.com]
    Sent: Tuesday, April 11, 2017 1:26 PM
    To: Multiple recipients of list PARTB-L
    Subject: [partb-l] Procedure with E&M

    I agree with Renee but you must have modifier -25 attached to the E&M as well as a different diagnosis from the diagnosis on the injection. In other words, use pain dx for the E&M and the actual problem (i.e. osteoarthritis, adhesive capsulitis, etc.) dx for the injection.

    Maryann Cross
    Certified Coding/Billing Specialist
    Central Carolina Orthopaedic Associates
    1139 Carthage St., Ste 101
    Sanford, NC 27330
    919-774-1355
    919-775-1644 (fax)
  • The pain in generally a symptom of the condition; if this is Medicare and the condition is established i.e. they have had injection before for the same condition they only report the injection procedure. If it's first time then you are ok with E &M

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • Yes and no, depends on payers but they tightening up the strings on this. See my first response..

    Karyn Cardenas-Foray, CPC, CPMA ,CHCA, CEMC,CIMC,CSEMC
    AHIMA ICD10 PROFICIENT
    Government Reimbursement Analyst-Sharp Health Care
    PFS-CCD 3rd Floor
    858-499-4382

  • For Medicare (and many commercials), even if it's a NEW patient, it must be separate and identifiable for an E/M to be billed.

    From the NCCI instructions...

    "If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

    The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles."


    It's important to note the two very important sentences about NEW patients...

    "If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure."

    So for both new and established patients, for Medicare, (and more and more commercials are following this too), the E/M is billable only if separate and identifiable from the procedure.


    Karl M Ellzey, President
    Ellzey Coding Solutions, Inc.
    www.ellzeycodingsolutions.com
    www.dermcoder.com
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