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karen57

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I was asked to pose this question to you to try to settle a debate in our office.

The date of service is in 2010 and the patient presents to the physician's office with a laceration. The laceration is repaired and the patient receives a tetanus shot. Are the office visit, the laceration repair and the tetanus shot all payable?

I know what I think, but I don't have a horse in the race :)

Thanks!

Karen
 
Debate

Actually the horse that wins is "yes". If the patient notes support modifiers 25 for the E/M and the doctor documents the lac repair and the tetnus you may recieve payment .
 
This is often a debated subject but I'll give my two cents-

If the office visit was not above and beyond the care inherent to repair the wound, I would say the laceration repair only w/ the tetanus shot; meaning a separate, identifiable E/M.

" Medicare payments for medical procedures include payments for certain evaluation and management (E/M) services that are necessary prior to the performance of a procedure. The Centers for Medicare & Medicaid Services (CMS) does not normally allow additional payments for separate E/M services performed by a provider on the same day as a
procedure. However, if a provider performs an E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure, modifier 25 may be attached to the claim to allow additional payment for the separate E/M service."

http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
 
Rebecca, if I understand correctly, you would list the laceration repair with the tetanus shot and would NOT list the EM code. Would you completely leave it out, OR code it without the modifier knowing that it will be bundled? Just solidifying the basics once again...

Suzanne E. Byrum CPC
 
ollielooya said:
Rebecca, if I understand correctly, you would list the laceration repair with the tetanus shot and would NOT list the EM code. Would you completely leave it out, OR code it without the modifier knowing that it will be bundled? Just solidifying the basics once again...

Suzanne E. Byrum CPC
Click to expand...

Depending on the documentation...If there isn't a separate, identifiable reason for the E/M, I would not report it. There will be cases when there is a separate issue at hand but if it's obvious that there are no other problems, complaints, I would only report the repair and the tetanus. I'm absolutley of the mind set that the provider is entitled to receiving max reimbursement but I also caution against voluminous documentation to achieve an E/M if not warranted.
 
I completely agree with Rebecca. The E/M documentation would have to show as "above and beyond" to be billed in addition to the procedure which has an E/M component built in.
 
This is always a big debate.

I would have to see the documentation to be absolutely certain per the case, but the way I see this from what you have posted, yes. The reason is the patient came in with the laceration, the patient had to be evaluated and assesed before the decision was made if it needed or how it needed to be repaired.

If the patient had come in say the day before with the laceration and the provider felt it didn't need repair, but than the patient came back in the next day or a few days later due to the laceration not healing and the decision was made to repair at the time, I would say no E/M only the procedure.

or, say the patient was seen by another provider for the laceration and than was sent to your office for the repair, than I would also say no E/M, unless your provider had to evaluate another complaint. The reason for the visit to your office was for the repair of the laceration, so the evaluation prior to the repair would be included in the repair.
 
Rebecca,

What would you consider usual pre-operative care for this patient? I would have agreed with tuliphaven that an initial assessment of the patient and plan for treatment (the lac repair) would have appropriated the E/M. Your comment, however, has me second guessing. This is such a gray area, if there are some specific guidelines, outside of the definition for modifier 25, I would sure like to read them.
 
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