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Thread: Em and procedures

  1. #1
    Join Date
    Apr 2007
    Traverse city/ Detroit

    Default Em and procedures

    AAPC: Back to School
    Thank you problem solved
    Last edited by geminitc81; 02-17-2010 at 08:46 AM.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    You may NOT upcode an office visit to "make up" for a procedure that is not being reimbursed. You may up code only when the docuemntation by the physician meets the criteria for counseling or coordination of care and time spent by the physician is documented. So every time you follow this directive by your office manager you are doing something wrong! You need to investigate why these procedures are not reimbursing. Impacted cerumen removal is reimbursed if it is performed by the physician and involves the use of a scoop or currette, this is NOT an ear irrigation, and the physician must write a procedure note. Then you put the 25 modifier on the E&M and if it is not paid you appeal. The aerosol should be paid with an office visit if you use the 25, what does the denial state?
    Debra Mitchell, MSPH, CPC-H

  3. #3


    It does make sense because the amount of work considered when rendering the office visit has increased, so the higher level is warranted. On the other hand, if you are properly documenting services performed, you should be getting paid for both the visit and the procedure with a -25 modifier.

  4. #4
    Join Date
    Apr 2007
    Boston, MA


    Upcoding is definitely NOT the answer. Debra has put it very nicely and I agree with her post. Check your documentation and see what was really done and make sure you have the right code for the procedure, then submit your "clean claim" and if you get a denial check why they deny. Based on that you can research and appeal. Don't default to charging extra for one service because you're not getting paid for another. That is just wrong and can lead to a lot of trouble.
    Karolina, CPC, CPMA, CEMC

  5. #5
    Join Date
    Apr 2007
    Duluth, Minnesota


    upcoding - is fraud -
    cerumen removal has VERY SPECIFIC guidelines in order to paid out separately - IF the procedure performed meets those guidelines, you can appeal for payment and prove it was done according to guidelines and deserves to be paid separately. (of course the E/M has a modifer on it due to the procedure IF it meets requirements - a simple lavage/washing does not constitute "cerumen removal".

    as for Neb tx's - we mark it and modifier the E/M but I don't think we're ever paid separately for it either - the insurances bundle it and apparently, if that's the contract, that's the way it is...they won't pay separately for it.
    Donna, CPC, CPC-H

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