Question Do in office procedures count toward MDM column 3?

JoannaParz

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Cedar Knolls, NJ
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If a physician decides to give and bill for an injection during an office visit does this count toward the MDM (column 3)?

  • Patient presented with plantar fasciitis which is progressing in pain over the past several months.
  • The provider then performed below injection: "At this time, the foot was injected with 1 cc of Kenalog 10 and 1 cc of 0.5% Marcaine plain under ultrasound guidance . The ultrasound findings was reviewed with the patient which shows a hypoechoic signal to the area measuring 0.45"

We want to ensure that we are not "double dipping" when it comes to performing and billing for injections, therefore if we do not count the injection toward RX management/decision for minor surgery this would drop the visit to a level 3.

Any links to instructing either counting or or not would be extremely helpful!

thank you
 

thomas7331

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CMS is quite clear that the initial evaluation and the decision to perform a minor procedure, when done on the same day of the procedure, are included in the global package and not separately billable. You can reference this publication: Global Surgery Booklet. On page 6: 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. And on page 9: When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure.

Since the work of the decision for that procedure cannot be billed, it therefor cannot be counted toward any E&M service done that day, and will also not support the use of the modifier 25. The information you've shared from the note above would not support billing any visit at all, actually, unless there is other unrelated information that you haven't included.
 
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