Wiki EM visit billed with Infusions & Chemo

[caroline75771]

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

 

[caroline75771]

Please any takers???

 

[mitchellde]

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.

 

[caroline75771]

Thank you Debra!