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Minor surgery

  1. #1
    Santa Barbara
    Default Minor surgery
    Medical Coding Books

    I found in the "Coding Answer Book ", "The initial evaluation or consultation of a new patient is not included in the global surgery payment. Therefore, Medicare should reimburse for new patient visits, even if the visit is on the same day as the procedure."

    However,the NCCI edits read,"The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

    Which is it?

  2. Default
    If it is an initial evaluation then you just need to put the Modifier 25 on it and it should be paid.

  3. #3
    North Carolina
    Medicare does have some contradictory verbiage within their guidelines...such as....

    Services Not Included in the Global Surgical Package

    The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;

    I do not agree with the statement that E/M is always included in the allowance for a minor procedure. There are situations where it is medically necessary to bill for an E/M in addition to the minor procedure. If the provider properly documents the history/ROS/ and examination to establish a treatment plan, medical necessity should be met. If you have a patient that has a laceration but also has other co-morbidities that could impact the healing process, a E/M could very well be justified assuming there is supportive documentation.

    Trailblazer has a better definition what constitutes an E/M service with a minor procedure.

    "The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding the 25 modifier to the appropriate level of E/M service.”

    In addition to the procedure, your provider should be paid for the mental process that it took to derive to the treatment plan if it's medically necessary and thoroughly documented.
    Last edited by RebeccaWoodward*; 04-30-2009 at 01:47 PM.
    Rebecca CPC, CPMA, CEMC

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