Question E&M with Office procedures

stannler

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I have returned to coding after being out of the field for 2 years. I work for an ENT practice. This may be a very basic question, but I need some clarification. A NEW patient is referred to us for a hematoma of the ear. There is some confusion on whether we can bill an E&M (99202) AND drainage of hematoma (69005) because this is a NEW patient. The only complaint addressed in the visit is the ear. My understanding is that in this case, we would only bill the office procedure, 69005, as this procedure would inherently include E&M. Is this correct? Does the fact that it is NEW vs EST patient have any bearing on the scenario? Also, I assume IF we can bill both, we would use a modifier 25 with the E&M. Also, if anyone can direct me to the specific guideline/source, , I would greatly appreciate it. Thank you! Sean
 

MSCALLIE79

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Modifier -25 is defined as a significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure. When you submit a minor procedure the same day as a new patient exam, you don’t need modifier -25.
  • The new-patient codes include 92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345.
  • You only need to append modifier -25 to the new patient exam if there is a CCI bundling edit for the procedure.
  • Minor procedures consist of those with a global period of 0 or 10 days.
  • The diagnosis on the exam may be the same or different from the procedure performed.
 
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I have returned to coding after being out of the field for 2 years. I work for an ENT practice. This may be a very basic question, but I need some clarification. A NEW patient is referred to us for a hematoma of the ear. There is some confusion on whether we can bill an E&M (99202) AND drainage of hematoma (69005) because this is a NEW patient. The only complaint addressed in the visit is the ear. My understanding is that in this case, we would only bill the office procedure, 69005, as this procedure would inherently include E&M. Is this correct? Does the fact that it is NEW vs EST patient have any bearing on the scenario? Also, I assume IF we can bill both, we would use a modifier 25 with the E&M. Also, if anyone can direct me to the specific guideline/source, , I would greatly appreciate it. Thank you! Sean

Hi,

For Medicare and private payers that follow CCI guidelines the fact that the patient is new will not have any bearing on whether you can report 25. That is, the ability to report the E/M visit isn't automatic for new patients. From the CCI manual, chapter 1:

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 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.
So it would come down to whether the E/M visit meets the full definition of 25, see Appendix A of the CPT manual for the complete descriptor. In this case it sounds like the patient was coming into have the hematoma treated, so the work up would be included. Again, this is a CCI guideline so it may not apply. If the payer doesn't follow CCI, I recommend checking for a modifier 25 policy.
 

stannler

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Thank you for the feedback,. I really appreciate it.
Modifier -25 is defined as a significant and separately identifiable evaluation and management service by the same physician on the same day of the procedure. When you submit a minor procedure the same day as a new patient exam, you don’t need modifier -25.
  • The new-patient codes include 92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345.
  • You only need to append modifier -25 to the new patient exam if there is a CCI bundling edit for the procedure.
  • Minor procedures consist of those with a global period of 0 or 10 days.
  • The diagnosis on the exam may be the same or different from the procedure performed.
Thank you!
 

stannler

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Hi,

For Medicare and private payers that follow CCI guidelines the fact that the patient is new will not have any bearing on whether you can report 25. That is, the ability to report the E/M visit isn't automatic for new patients. From the CCI manual, chapter 1:



So it would come down to whether the E/M visit meets the full definition of 25, see Appendix A of the CPT manual for the complete descriptor. In this case it sounds like the patient was coming into have the hematoma treated, so the work up would be included. Again, this is a CCI guideline so it may not apply. If the payer doesn't follow CCI, I recommend checking for a modifier 25 policy.
Thank you
 
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