Wiki Unblundling E/M with procedures

[KaitlynEFitch]

My questions are these:

1. How do I know when to use an E/M code?

2. How do I know whether or not an E/M code is already included in a procedure? (such as 96900)

 

[OCD_coder]

This is a complex topic. To know whether a procedure has an E&M component is a challenge. You have to understand the global package rules and the global status indicators. These both can be found on the RBRVU Fee Schedule.

If the procedure has a global status indicator of XXX (95900), there is NO E&M component to the code so a E&M can be reported if documented appropriately to support the level and the minor procedure rules do not apply. Medicare requires a modifier 25 on the E&M when reporting both.
Source; NCCI Coding Manual, Chapt 1, General Guidelines

If the global status indicator is 00 - 010 for a minor procedure, then a "brief" E&M is inclusive of the procedure for preprocedural clearance and work. Medicare states that making the decision to perform the minor procedure is not enough to support a separate E&M. Understanding when it is "significant" enough to support a separate E&M, as a separate diagnosis is not required, is a challenge. Many of our MCR MACS have examples of when a separate E&M is billable. It could be a prescription for the underlying problem or maybe diagnostic workup that is separate from the minor procedure to determine the treatment plan. This are just some examples, there could be other scenarios that work. Apply a modifier 25 to the E&M. If two problems are treated on the same day be sure to link the diagnosis to each service separately to make it clear they are separate.

Lastly, Medicare rules state that the initial consultation is not part of a major procedure. So the E&M service and procedure are reportable on the same day and require a modifier 57 on the E&M.