Separate E/M with Screening Colonoscopy, Plus Pre-op Screenings

Dear John

Q: I’m trying to find a specific, CMS reference that clarifies billing for an E/M service with screening colonoscopy and billing for colonoscopy done for pre-op reasons. A GI provider recently joined our group, and we want these issues to be settled, right from the start.

Trude Vozzella, CPC, CEMC

A: The definitive Centers for Medicare & Medicaid Services (CMS) text for screening colonoscopy is chapter 18 – Preventive and Screening Services, section 60 of the Medicare Claims Processing Manual. The manual details the patient requirement for which CMS will cover a screening colonoscopy, the proper codes to apply, and frequency limitations. Unfortunately, it does not provide specific guidance relative to billing an evaluation and management (E/M) service in addition to a (covered or non-covered) screening exam.

CMS does, however, offer ample general guidance on when you may report a separate E/M service with a minor surgical or endoscopic procedure. Two of many possible examples include:

Evaluation and Management – CEMC

CMS National Correct Coding Initiative manual states:

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. … 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.

The CMS Global Surgery Fact Sheet specifies:

The initial evaluation for minor surgical procedures and endoscopies [this would include screening colonoscopy] is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier 25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.

In other words, if the patient is otherwise healthy, CMS guidelines confirm you should not report an E/M with the screening colonoscopy. Only when a patient requires an E/M service that goes beyond the “usual” service— supported by documentation of a medically-necessary history, exam, and medical decision-making—may a separate E/M code be reported, with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.

CMS guidance on this issue is widely observed by commercial payers, as well as provider advocacy groups. For example, the American Gastroenterological Association advises on its website:

How do I bill for a patient seen in our office prior to a screening colonoscopy with no GI symptoms and who is otherwise healthy?

A visit prior to a screening colonoscopy for a healthy patient is not billable.

If a patient is referred to our office for a screening colonoscopy and the patient is on warfarin, can we bill for the visit?

Yes. If the patient requires some intervention on the part of the gastroenterologist prior to the procedure, you can bill a New Patient or Established Patient visit, depending on whether the patient has received any face-to-face service by any provider of the same specialty in your office within the last three years.

Guidelines for separately billing pre-operative services to Medicare may be found in CMS Transmittal 1719:

F. Applicability of §1862(a)(7) of the Act to Preoperative Services.

Preoperative Examinations. For purposes of billing under the Physician Fee Schedule, medical preoperative examinations performed by, or at the request of, the attending surgeon does not fall within the statutory exclusion articulated in §1862(a)(7) of the Act. These examinations are payable if they are medically necessary (i.e., based on a determination of medical necessity under §1862(a)(1)(A) of the Act) and meet the documentation requirements of the service billed. Determination of the appropriate E/M code is based on the requirements of the specific type and level of visit or consultation the physician submits on his claim (e.g., established patient, new patient, consultation).

Preoperative Diagnostic Tests. When billing under the Physician Fee Schedule, preoperative diagnostic tests performed by, or at the request of, the physician performing preoperative examinations, do not fall within the statutory exclusion articulated in §1862(a)(7) of the Act. These diagnostic tests are payable if they are medically necessary (i.e., they may be denied under §1862(a)(1)(A)).

G. ICD Coding Requirements for Preoperative Services. All claims for preoperative medical accompanied by the appropriate ICD-9 code for preoperative examination (e.g., V72.81 through V72.84). Additional appropriate ICD-9 codes for the condition(s) that prompted surgery and for conditions that prompted the preoperative medical evaluation (if any), should also be documented on the claim. Other diagnoses and conditions affecting the patient may also be documented on the claim, if appropriate. The ICD-9 code that appears in the line item of a preoperative examination or diagnostic test must be the code for the appropriate preoperative examination (e.g., V72.81 through V72.84).

H. Reasonable and Necessary Services. For the purpose of establishing preoperative services as reasonable and necessary, all claims are subject to applicable national coverage decisions. In the absence of a national coverage decision, reasonable and necessary services are determined by carrier discretion. Establishing reasonable and necessary preoperative medical evaluations is facilitated when the ICD-9 codes(s) for the condition(s) that prompted surgery, and for the conditions that prompted the preoperative medical evaluation (if any), are documented as additional diagnoses on the claim.

The bottom line: CMS will not pay separately for routine pre-op screening colonoscopy (or other routine pre-surgical screening).

Assuming that the patient does not meet the screening criteria described in chapter 18, section 60 of the Medicare Claims Processing Manual, a pre-op colonoscopy may be reported and paid separately only if the medical record substantiates medical necessity for the service—for instance, if the patient develops a new problem (or other significant change of status) in the days prior to surgery. In such a case, CMS requires you to cite an ICD-9-CM code for preoperative examination (V72.81-V72.84), but also warns, “these ICD-9 codes do not, in and of themselves, establish medical necessity, therefore claims containing these codes may be subject to medical necessity determinations as described in §15047 H” [cited above].

To charge a patient separately for a non-covered pre-op screening would be unbundling, and might constitute fraudulent billing. If the gastroenterologist is performing routine (as opposed to medically-necessary) screenings at the surgeons’ request, he or she may have to seek reimbursement directly from the referring surgeon.

 

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

2017-code-book-bundles-728x90-01

Michelle Dick
Follow me

Michelle Dick

Executive Editor at AAPC
Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.
Michelle Dick
Follow me

About Has 134 Posts

Michelle A. Dick has been executive editor for AAPC for over seven years. Prior to her work at AAPC, she was editor-in-chief at Eli Research and Element K Journals, and disk ad coordinator, web designer/developer, and graphic artist at White Directory Publishers, Inc. Dick has a Bachelor of Science in Graphic Design from the State University of New York - Buffalo State and is a member of the Flower City Professional Coders in Rochester, N.Y.

One Response to “Separate E/M with Screening Colonoscopy, Plus Pre-op Screenings”

  1. Jo says:

    Please clarify what “prior” is. Do you mean the day of the screening or does this imply to any date prior to colonoscopy.

Leave a Reply

Your email address will not be published. Required fields are marked *