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New pain patient

  1. #1
    Default New pain patient
    Medical Coding Books
    When your clinic sees a patient for the 1st time and performs an epidural, do you code the new patient visit as well as the injection code? 99203, 62311.

  2. #2
    Default
    Yes, we do. The office visit will have to have a -25 modifier. A new patient visit is "above and beyond" the usual office vist that is normally bundled with a procedure, therefore it is separately payable.

  3. #3
    Default
    cbunti,

    I do not agree with the blanket statement that it's appropriate to bill an E&M on every new pain patient. I'm guessing that most of your pain procedures have a 0 or 10 day global period which is a minor surgical procedure. NCCI is very clear on this point. The -25 modifier over-rides the edit allowing payment and is telling the payer that the E&M is significant, separately identifiable from the procedure which I don't believe is ALWAYS the case. I have attached the NCCI link and excerpt below:

    http://www.cms.hhs.gov/NationalCorre....asp#TopOfPage

    "If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. 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. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles."

    Julie, CPC
    Last edited by jdrueppel; 10-14-2009 at 07:12 PM.

  4. #4
    Default
    Quote Originally Posted by jdrueppel View Post
    cbunti,

    I do not agree with the blanket statement that it's appropriate to bill an E&M on every new pain patient. I'm guessing that most of your pain procedures have a 0 or 10 day global period which is a minor surgical procedure. NCCI is very clear on this point. The -25 modifier over-rides the edit allowing payment and is telling the payer that the E&M is significant, separately identifiable from the procedure which I don't believe is ALWAYS the case. I have attached the NCCI link and excerpt below:

    http://www.cms.hhs.gov/NationalCorre....asp#TopOfPage

    "If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. 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. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles."

    Julie, CPC
    Excellent point!!! I stand corrected!

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