E/M w/ Injection and or Procedure

mv0129

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Need clarification on billing e/m with procedure. Would it be appropriate to only bill the E/M based on the RVU's instead of the procedure?
 

CodingKing

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No. If the procedure has a code you would use the code for the procedure. You cant bill the E&M just because it has a higher RVU than the procedure its bundled into.
 

wynonna

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injection

In the case of vaccines, you can sometimes bill for the vaccine (flu, prevnar, hepatitis, zoster, etc) AND for the injection code. (90471 for non-Medicare,) and G0008 (-flu for Medicare) or G0009 (-Prevnar and pneumonia shots for Medicare), generally speaking. So, 90471, G0008, and G0009 are for the shots (injections) while vaccine products (what is being injected for immunizations) are coded separately.
Office visit code must meet History, Exam, and Med Dec Making qualifications. Office visit in addition to vaccine injections is exemplified in the case where the patient presents for a Wellness, Physical, or Office visit and is offered and given a flu shot or immunization in addition to a documented E & M visit. So the office visit and flu shot (flu vaccine code and injection code), and/or vaccination code plus injection code are all billed together.
There may be exceptions, but generally both an injection code and vaccine code can be billed together, or 2 codes per vaccine administered.
 

CodingKing

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First according to the first page on the intro to the introduction to the CPT book? "Select the name of the procedure that accurately describes the services performed"

https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

From the OIG report of E&M on same day as procedure:

Evaluation and management (E/M) services that are necessary for the
performance of a medical procedure (for example, assessing the
site/condition of the problem area, explaining the procedure, and
obtaining informed consent) are included in Medicare payments for the
procedure.1

CPT Assistant,” Vol. 8, Issue 9, September 1998.

If the E&M would not have been separately reimbursed in addition to the procedure, what makes this E&M meet the standards of reporting the E&M by itself? This would be a perfect example of upcoding. I could understand if the coding guidelines bundle the minor procedure into the E&M and don't allow separate reporting of the procedure (for instance Status B-bundled CPT codes)
 
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