Coding E&M with a "preplanned procedure".


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Pt comes in for IV hydration procedure for the first time at an urgent care center. The patient is scheduled to come back weekly for IV hydration for five weeks. I told my provider he can only charge an E&M with the hydration procedure the first day and he could not charge for an office visit for all the upcoming hydrations because they are "preplanned" and scheduled ahead. The only way we could code an E&M with those repeat hydrations was if there was a change or pt has a complaint. He does not agree with me and needs me to prove it. I know i read somewhere from the AMA the rule to go by when you are doing "preplanned" procedures. Can anyone help me find that rule that tells us we cannot charge for an office visits when the procedure is preplanned? This patient in particular has Carefirst insurance. any help appreciated.


True Blue
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The rule of thumb (not a coding guideline) that you can't charge an E/M if the patient was already scheduled for a procedure usually applies to surgical procedures where the patient was previously evaluated for a particular condition that requires surgery and then arrives at a later date for the procedure itself (e.g. for the excision of a skin lesion that the provider had determined needed to be removed). In a situation like that, there wouldn't be medical necessity for another E/M visit unless the patient's condition had changed or there was a new problem since the last visit.

I think your situation is a little different - hydration isn't a surgical procedure but rather is a therapeutic treatment for an underlying disease process. Providers typically need to re-evaluate patients to assess their response to infusion services, just as they might need to have a follow-up visit to see if the patient was responding to a prescription drug. I would consider that, in most cases, to be part of the treatment of the underlying condition, and not E/M that is associated with the procedure itself. It will of course depend on documentation, and you will need to support a modifier 25 to show that the provider has performed an E/M service that is significant and separately identifiable from the any E/M associated with the hydration service itself (which would be minimal), but there isn't a rule that says that an E/M service cannot be billed simply because the service was 'preplanned'.