When an office procedure, say, Examination Of The Ears Under General Anesthesia ($50), is far less than the cost of an office visit ($150) but this was the only thing addressed at the office visit, am I correct in concluding only the procedure can be charged?
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Office Procedure/ E/M visit (-25)
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thomas7331
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It really depends on what is documented. Typically if a procedure is planned in advance and that's the only thing done, then an E&M charge is not warranted. But if the patient is being evaluated for a problem, and during the course of the evaluation the provider determines that the procedure is a necessary step in the diagnosis of the problem and/or formation of a plan of care, you can probably justify the E&M service and modifier 25.
But are they really doing an exam under general anesthesia in the office (92502)? General anesthesia is usually a facility service and the code is set up in the RVU table with a non-facility 'NA' indicator which means 'rarely or never performed in the non-facility setting.' If you're using 92502, that's why you're seeing such low payment - the code is valued just on the physician work and is not set up to capture any of your facility costs.
But are they really doing an exam under general anesthesia in the office (92502)? General anesthesia is usually a facility service and the code is set up in the RVU table with a non-facility 'NA' indicator which means 'rarely or never performed in the non-facility setting.' If you're using 92502, that's why you're seeing such low payment - the code is valued just on the physician work and is not set up to capture any of your facility costs.
danskangel313
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I agree with what was previously posted regarding the documentation being a crucial part of how to code for this. Unfortunately 92502 includes the anesthesia so that couldn't be billed separately.
I do have a question - when you're referring to the cost for the service as $50, is that the price charged out by the office or is that the reimbursement you're receiving? I only ask because if you're billing for the service with a price far below a fee schedule amount, then that's what you'll get paid. I quickly glanced at the MC fee schedule and it showed around $100-ish for this code; if you're only charging $50, that's what you'll be getting. (Aside from the whole facility vs non-facility issue)