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Wiki Planned Procedures

T

torih@nwurology.com

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I have always been told that if a procedure is planned and no additional diagnosis is found, an E&M should not be billed. Does anyone know what the time frame is for a procedure being "Planned"? I work in a Urology office and patients return to the clinic for a Cysto every 3, 6 or 12 months.

Thank you
Tori:confused:
 
Are you talking about the one E/M service on the day of the procedure (or the day preceding) as part of the surgical package? If so, that is correct - you could not bill for that separately.
 
In that case, yes, the visit may be billed. It would not be considered part of the surgical package that far in advance of the procedure. There is modifier -57 for the surigcal decision, but that is used for visits that would fall under the package, not for something like this, a week or month before the surgery. Does the person(s) who told you this have a citation from which they found this information?
 
That's one of the problems with coding...too many gray areas and it's hard to find something in writing. I have a feeling a lot of the info is just hearsay and passed along between people.

Would it be different if the appointment was scheduled for an actual procedure and then a visit was billed?

Thanks for your input.

Tori
 
If the visit in which the procedure was scheduled contained all three key elements properly documented and was medically necessary, then yes, you could bill for that visit. The physician may have provided treatment such as pain management so the patient could be comfortable before the procedure, or medication given to prevent an infection before the procedure. These would be medically necessary, and assuming that the proper history and examinaton was performed and documented, why shouldn't the visit be billed? A service was provided....
 
I have a similar, but different question, LOL

I have searched high and low for an answer to this question and I cannot come to a definite conclusion.

Question: During the course of a planned surgical procedure, if the surgeon discovers some pathology requiring maneuvers that are NOT a part of the major procedure or global surgery package, something considered by the surgeon to be medically necessary and perhaps unrelated to the planned procedure, is this separately reportable? I do not have a specific example at this time.

What is known: In page 10, chapter 1 of the CMS NCCI Policy manual, it is clearly outlined what is considered integral to a planned surgical procedure... a smaller portion inclusive of a larger procedure. This chapter also covers sequential procedures, conversions, and intraoperative complications and what is not separately reportable.

But, Ch1, page 15 of NCCI Policy Manual states: "If exploration of the surgical field results in additional procedures other than the primary procedure, the additional procedures may generally be reported separately." CMS 2018 NCCI Policy Manual, Ch1, General Correct Coding Policies

Can anyone help me out with this?
 
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