E/m on same day as procedure

[nailszr5]

My physician performed a removal of central venous catheter in the office. Can I also bill for an E/M service the same day?

 

[lhamilto@ufl.edu]

I think that would depend on what else was documented. If the decision for the procedure was made on the same day, the e&m could be billed with the 24 modifier, in my opinion. Were any other conditions evaluated? The global period only covers services that are directly related to the surgery.

 

[dappy]

I think that would depend on what else was documented. If the decision for the procedure was made on the same day, the e&m could be billed with the 24 modifier, in my opinion. Were any other conditions evaluated? The global period only covers services that are directly related to the surgery.

The National Correct Coding Initiative (NCCI) 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. …

And the CMS manual states that "The initial evaluation is always included in the allowance for a minor surgical procedure."
That is, the payment for evaluating the condition and deciding to perform a procedure is considered part of the payment for the procedure, unless there is a significant and separately identifiable service performed. Do not report a separate E&M service for a planned procedure. Many minor procedures on healthy patients do not require a separate E&M, such as lesion destruction or punch biopsy. The clinician is paid for the evaluation of the lesion as part of the destruction or biopsy. It is permissible to report an E&M service for an unrelated problem or when the problem being evaluated wouldn't necessarily result in the procedure.

Hope this helps