If one of our physicians performs an anoscopy during the physicial exam of an office visit, should the anoscopy have a separate OP report? The physicians feel that including a brief description of the procedure and findings in their office notes meets the requirements for billing an anoscopy, since it is such a quick and minor procedure. Do you feel this is correct?
Does your office require your physicians to dictate a separate OP report?
Also, can PA's perform and bill for anoscopies?
If clearly outlined
As long as the procedure itself is clearly outlined in a separate paragraph of the clinic note you should be fine. BUT it is NOT enough to have "will perform anoscopy" in the Assessment/plan section. Saying you are going to do something is not the same as documenting that you did it.
For our practice, the equivalent procedure is a simple laceration repair.
If it is in their scope of practice, I would think that PAs should be able to perform and bill anoscopy under their own name/number.
Hope that helps,
F Tessa Bartels, CPC, CEMC
I have a question about the anoscopy. I am trying to figure out the correct way. I have been told that you should bill the appropriate E/M level with 25 modifier and the anoscopy. I have also been told that you should just bill the appropriate E/M level and not the anoscopy because you get credit for doing the anoscopy when you do the exam portion on the patient.
Can any one in gastro clear this up for me? I have not dealt much in this area.
Anoscopy with E/M
Hi! Yes, bill the appropriate E/M level with a modifier "25" appended, Then use the appropriate anoscopy code for the service provided. My physicians document the anoscopy with the letters "ano" and a positive or negative sign after it. Hope this helps.
As long as you are not just appending the modifier to get paid. The E&M service still has to meet the "significant, separately identifiable" requirement.