Be Careful When Considering Coding E/Ms With Minor Procedures
Question: Is it possible to report a minor procedure and a separate emergency department (ED) evaluation and management (E/M) service when the physician treats only one condition? AAPC Forum Participant Answer: Sometimes. Given that the ED physician has to perform some sort of E/M for each patient that reports, an E/M service will occur before they perform a minor procedure — but when it’s for the same problem, the E/M is often considered part of the pre-service work. In those cases, you cannot code a minor procedure and a separate E/M. According to the American College of Surgeons (ACS), “It is important to note that the RVU [relative value unit] for each minor procedure includes pre-service work. Reporting an E/M code and a procedure code when your evaluation is limited to assessing the specific problem is essentially double-billing for the pre-service evaluation.” In order to report an E/M along with a minor procedure, “your E/M must significantly exceed the pre-service evaluation already paid as part of the procedure for it to qualify as significant and separately identifiable. If it does not, only the procedure should be billed,” according to ACS. “A significant E/M service is provided at the time of a minor procedure when a separate aspect of care is addressed and clearly shows a separate and distinct management option, or options, is being, or has been, pursued at the visit,” says Nate Felt, MS, CPC, ATC, PTA. “The documentation should give adequate detail justifying that significant additional work was done.” Example: The ED physician performs arthrocentesis on a patient’s knee. The documented exam shows quad weakness, poor range of motion (ROM), and a high body mass index (BMI). Documentation shows that the ED physician spent significant time discussing weight loss and surgical options. The ED physician also orders physical therapy for the patient to improve ROM and quad strength. In this case, you could report 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) and a code from the 99281-99285 (Emergency department visit for the evaluation and management of a patient …) set for the ED E/M. Don’t forget to append 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) to 20610 to show that the arthrocentesis and ED E/M were significant, separately identifiable services. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
