Wiki E/M billed along with IV infusion

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clopez

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Hello,

Im currently auditing a practice where I'm seeing a trend in how IV infusion is being billed along with a separate E/M The reason for visit states IV infusion
the Exam is just vital signs and the MDM is Medications ordered for therapeutic infusion.

I don't agree with how they are billing because this looks more like a trend then medical necessity.

Are others seeing this type of trend and how do you address it to your providers.

Any reference tools used would be greatly appreciated, So far the reference I will use is Medicare claims processing manual Chapter 12 section 30.5


Thank you in advance:eek:
 
The AAPC coder offers: "If a significant, separately identifiable office or other outpatient Evaluation and Management service is performed, the appropriate E/M service (99201-99215, 99241-99245, 99354-99355) should be reported using modifier 25 in addition to 96360-96549. For same day E/M service, a different diagnosis is not required. "
From what you describe, I don't see a "significant" E&M and if the carrier audits for these type of claims, it will be bad news....it simply is not worth the risk to send out these claims without proper documentation to support the claim.
 
1995/1997 documentation guidelines

If the required key component documentation criteria is not met then E/M is not warranted.


Evaluation and Management CPT Guidelines:

When assigning an E/M level of service you must determine the extent of history obtained, the examination performed, and the complexity of medical decision making.

The 1995 documentation guidelines specify the necessary criterion that is required for each level of service.
 
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