Wiki Billing an E & M on the same day as a minor procedure.

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tswitzer

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I have a letter that we received for a RAC audit on a couple of claims from one of our general surgeons. The provider saw the patient as an inpatient and it was decided that we needed to perform an EGD on one and an I & D on another. The E & M was appended with a 57 modifier. The letter states that the E & M is not payable with a 57 modifier when the procedure has a 0 or 10 day global period. Both procedures have a 0 day global which to me means that NOTHING else is included in the CPT for the procedure. I found some samples that talk about a 25 modifier. I see noting in the description saying it included an E & M so I an wondering if the real issue is it should have had a modifier not a 57. Both times the patient was taken to a procedure room, it was not done in the hospital room. I felt like it was billed correctly but I am confused now.
 
This is from the CMS global surgery booklet:
Note: The initial evaluation for minor surgical procedures and endoscopies 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.
https://www.cms.gov/Outreach-and-Ed...oducts/downloads/GloballSurgery-ICN907166.pdf
I advise my providers that the E/M has to support additional treatment outside of the procedure to support a modifier 25.
 
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