Wiki New pain patient

[cbunti]

When your clinic sees a patient for the 1st time and performs an epidural, do you code the new patient visit as well as the injection code? 99203, 62311.

 

[Walker22]

Yes, we do. The office visit will have to have a -25 modifier. A new patient visit is "above and beyond" the usual office vist that is normally bundled with a procedure, therefore it is separately payable.

 

[jdrueppel]

cbunti,

I do not agree with the blanket statement that it's appropriate to bill an E&M on every new pain patient. I'm guessing that most of your pain procedures have a 0 or 10 day global period which is a minor surgical procedure. NCCI is very clear on this point. The -25 modifier over-rides the edit allowing payment and is telling the payer that the E&M is significant, separately identifiable from the procedure which I don't believe is ALWAYS the case. I have attached the NCCI link and excerpt below:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage

"If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should 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 is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles."

Julie, CPC

 

[Walker22]

cbunti,

I do not agree with the blanket statement that it's appropriate to bill an E&M on every new pain patient. I'm guessing that most of your pain procedures have a 0 or 10 day global period which is a minor surgical procedure. NCCI is very clear on this point. The -25 modifier over-rides the edit allowing payment and is telling the payer that the E&M is significant, separately identifiable from the procedure which I don't believe is ALWAYS the case. I have attached the NCCI link and excerpt below:

http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage

"If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should 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 is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles."

Julie, CPC

Excellent point!!! I stand corrected!