Office Procedure/ E/M visit (-25)

sblacke68

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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?
 

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.
 

sblacke68

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That answer was very helpful, I will relay to the A/R specialist in our office who's working on this. I wondered the same concerning the general anesthesia code.

Thanks!
 
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That answer was very helpful, I will relay to the A/R specialist in our office who's working on this. I wondered the same concerning the general anesthesia code.

Thanks!

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)
 
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