Wiki Non-Scheduled Procedure- When is an E/M Appropriate

mcdream

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Hi all,

Evaluation of a NEW problem with procedure same day- when is an E/M appropriate?

Scenario: Patient presents for evaluation of a NEW straightforward problem (no other complaints, an otherwise healthy individual) and has procedure done for the problem same visit, such as wart destruction, skin tag removal, ear wax removal, nail removal, incision & drainage.

Question: Even though the clinician performed an evaluation, determined the diagnosis & decided to perform procedure, the problem itself is one that is necessarily to result in procedure (in other words the clinician knows just by looking at the patient's problem what the treatment option is), therefore it would only be permissible to report the procedure? Whereas it is permissible to report an E&M service when the problem being evaluated wouldn't necessarily result in procedure?

NCCI:
- "If a minor surgical procedure is performed on a NEW patient (NEW issue)...the fact that the patient is NEW is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure."
- "In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the global surgical package for the minor surgical procedure, and shall not be reported separately as an E/M service."

Thank you all, I look forward to hearing your thoughts.
 

https://www.aapc.com/blog/27690-know-when-to-bill-em-with-a-minor-procedure/

The Visit’s Purpose Can Help You Decide​

Even if the E/M service is related to the minor procedure, you still may be able to report it separately. Ask yourself: Did the E/M occur because of the procedure, or was the need to perform a minor procedure determined as a result of a significant (i.e., fully supported by documentation and includes the key elements of history, exam, and medical decision making (MDM)) E/M service? Only in the second case may you report the E/M in addition to the procedure.

If a new problem or exacerbation of an existing problem needs to be evaluated first before decision for procedure can be made, then an E/M can be charged.

Many payers bundle an evaluation and management (E/M) service when reported on the same day as a minor surgical procedure. National Correct Coding Initiative (NCCI) edits routinely bundle E/M services with minor surgical procedures, and the Centers for Medicare & Medicaid Services (CMS) policy dictates, “The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package” (Medicare Claims Processing Manual, Chapter 12, Section 40.1.B).

In spite of all of this, providers may (and should) report an E/M service performed on the same day as a minor surgical procedure, as long as medical necessity dictates the need for a separate, significant E/M, and the encounter is supported by documentation and reported with an appropriate modifier.

Interpreting the Rules​

A “minor procedure” is any procedure/CPT® code with a zero-day or 10-day global period, as defined by Medicare’s Physician Fee Schedule Relative Value File. Examples of minor procedures include many types of injections, minor integumentary repairs, and endoscopic procedures (e.g., diagnostic colonoscopy).

Per CMS rules, every procedure (whether major or minor) includes an “inherent” E/M component and, as such, you generally may not report a separate E/M service on the same date of service. This rule is repeated throughout CMS policy documents, but is succinctly explained in the Medicare Claims Processing Manual, Chapter 12, Section 40.1.C:

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.

The “unless” clause is important. It allows you to report (and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is “significant” and “separately identifiable.”


https://codingintel.com/decision-to-perform-a-minor-procedure/

What does the decision to perform a minor procedure really mean?​

I received this question recently and want to share it with you.

“Since the decision to perform a minor procedure is included in the payment for the minor procedure, does this mean we can never bill an E/M and a procedure on the same day for the same condition?”

It doesn’t mean you can never bill an E/M and a minor procedure on the same day. You can bill an E/M and a minor procedure (procedure with 0 or 10 global days) on the same calendar date.

The writer quoted the CMS Claims Processing Manual. The same language is in the CMS manual and the NCCI manual. I’m sure you’ve read it.

In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the 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.

The first and second sentences would lead you to believe you can’t. Then, the third and fourth sentences would lead you to believe you can. Both CPT® and CMS say that a different diagnosis is not required.

The procedure code includes typical pre and post work, not a significant and separate evaluation of a condition.

The NCCI manual does give one clinical example. Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.

Pre-work is site assessment, decision to perform the procedure, informed consent, obtaining information about allergies, obtaining information about immunization status, if relevant.

Post-work includes post procedural instructions.

When a physician/NP/PA needs to evaluate a condition and consider treatment options prior to the decision for surgery, bill for both.

In the latest edition of the AMA’s Principles of CPT® Coding 9th ed, there is a decision tree regarding using modifier 25. The first question in the tree is “Does the documentation support that’s the patient’s condition required a separate and distinct E/M service, above and beyond the usual preoperative and postoperative services for the procedure?” And, keep in mind that contrary to some payer edits, both CMS and CPT say that the same diagnosis may be used to report the E/M service and the procedure.

Procedures do have pre and post work valued into the procedure. But that work does not include a separate and significant evaluation of a condition that may or may not result in a procedure.
 
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