Wiki E/M with procedures in a Walk-in Clinic, not urgent Care

[Breesmom91]

Hello, we are having some back and forth in our office, our Physician group believes that they can bill a E/M with a procedure because it is done at the walk-in clinic. The coders are saying it does not matter if it is done at our walk-in clinic or not it cannot be billed together unless it is separately identifiable evaluation and management service. I would love to get your thoughts on this.

 

[jkyles]

Hi there, the coders are right. You're billing various payers for the services performed in the clinic and those payers have rules, including bundling edits. If the physician group believes there's some special exception for walk-in clinics they need to "show it to you in writing," as physicians often ask. Maybe they have a weird contract with one payer.

 

[Lera]

As far as that it has to be separately identifiable evaluation and management service, coders are right.
But from provider's standpoint - it is a walk-in clinic. Therefore, the problem that requires E&M and procedure on the same day, is most of the time new to the provider, for example not previously diagnosed or not previously scheduled procedure. And visit like this would normally exceed the minimal evaluation by provider. But it varies from visit to visit and must be explicitly supported by documentation that provider performed more work evaluating patient than simple straightforward decision to go ahead with the procedure.
And if so and it is supported by documentation then both E&M and procedures are billed with Mod 25 on the same DOS by the same provider. According to CPT® and the Centers for Medicare & Medicaid Services (CMS) guidelines, all procedures and services—no matter how minor—include an inherent E/M component. Any E/M service you report separately must exceed the minimal evaluation that normally accompanies any other same day service(s) or procedure(s).