EM visit billed with Infusions & Chemo

caroline

Guru
Messages
120
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0
Hi All,

Does anyone have a link or reference guide that I can provide to our providers which clearly spells out an EM can only be reported with infusions & chemo when there is medical necessity. Our providers feel they're entitled to an EM reimbursement every time a patient is scheduled for these treatments without supporting medical necessity.
I don't know how else to convey to them that this is fraud.

I have two specialties, Renal and Hematology that won't change their codiing behavior and need some concrete guidelines to convince them.

Please help!!
Thanks you.
Caroline
 

mitchellde

True Blue
Messages
13,429
Location
Columbia, MO
Best answers
1
This goes to the logic of the 25 modifier. You cannot charge an E&M when the patient has already been scheduled for a procedure or service since the medical necessity for the procedure has already been determined. If there is a reason to examine the patient beyond the predetermined procedure then you may have an E&M in addition but documentation must clearly reflect an assessment over above and beyond the necessity for the procedure.
In addition the MCM states that you cannot charge an E&M when the patient comes in for chemo unless it if for reason unrelated to the chemo.
 
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