Wiki E/M with New Hernia Repair codes for 2023

[Kathy Francis]

Example / Providers see's a New or Established patient in the office, the appropriate E/M is billed.
The surgery is scheduled to be performed in a couple of weeks. Ends up being under 30 days.
On the actual date of the surgery the provider is entering another E/M Code on the date of the surgery restating the plan as previous E/M.

Advise on this is greatly appreciated.

 

[jkyles]

Hi there, that isn't a separately billable E/M visit. The work and reimbursement is included in the surgery. It might help to review the CMS NCCI manual with the provider. https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-1.pdf

Since NCCI PTP edits are applied to same-day services by the same provider/supplier to the
same beneficiary, certain Global Surgery Rules are applicable to the NCCI program. An E&M
service is separately reportable on the same date of service as a procedure with a global period of
000, 010, or 090 under limited circumstances.

If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an
E&M service is performed on the same date of service as a major surgical procedure to decide
whether to perform this surgical procedure, the E&M service is separately reportable with
modifier 57. Other preoperative E&M services on the same date of service as a major surgical
procedure are included in the global payment for the procedure and are not separately reportable.
NCCI does not contain edits based on this rule because MACs have separate edits.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure.
In general, E&M services performed on the same date of service as a minor surgical procedure
are included in the payment for the procedure. The decision to perform a minor surgical
procedure is included in the payment for the minor surgical procedure and shall not be reported
separately as an E&M service. However, a significant and separately identifiable E&M service
unrelated to the decision to perform the minor surgical procedure is separately reportable with
modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.
If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M
services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to
justify reporting an E&M service on the same date of service as a minor surgical procedure.
NCCI contains many, but not all, possible edits based on these principles