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E/M coding w/Infusion

  1. Default E/M coding w/Infusion
    Medical Coding Books
    My providers perform scheduled infusions for arthritis treatment. At the conclusion of the infusion the provider sees the patient and reports an E/M visit. We are applying the 25 modifier however my concern is, is it allowable to bill the E/M level in conjunction with the infusion if (a) there are no problems during the infusion or (b) the patient does not report any problems pre-infusion. The notes do indicate review of symptoms as related to the condition as well as vitals and medications taken daily.


    I appreciate any and all information regarding this situation.

    Thanks

    Karolyn

  2. Default E/M needs to significant separately identifiable
    from what you are stating below, the E/M is bundled/included in the infusion. Modifier 25 is ONLY to be used if there is a significant, separately identifiable E/M by the same physician on the same day of the procedure or service. With there being no problems during the infusion, no problems pre-infusion there is nothing separately identifiable. You may want to review Appendix A and the definition of modifier 25. There is alot of discussion of medical necessity (OIG plan), if there are no problems pre or during, based on your description, there is no medical necessity of the E/M visit. There is documentation on this within the Medicare Manual on CMS website, I think it is in Chapter 12 of the Medicare Claims Processing Manual. http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage

    If you can't find the documentation, email me at jhs91903@yahoo.com and I will see if I can find it for you.

    Joyce

    Quote Originally Posted by kpennington View Post
    My providers perform scheduled infusions for arthritis treatment. At the conclusion of the infusion the provider sees the patient and reports an E/M visit. We are applying the 25 modifier however my concern is, is it allowable to bill the E/M level in conjunction with the infusion if (a) there are no problems during the infusion or (b) the patient does not report any problems pre-infusion. The notes do indicate review of symptoms as related to the condition as well as vitals and medications taken daily.


    I appreciate any and all information regarding this situation.

    Thanks

    Karolyn

  3. Default
    Thank you very much for your response.

    This is what I thought, I just need to get clarification and documentation to support this subject before taking it any further with providers and administrator. I have voiced my concern that we are not reporting this properly so I just need to get my ducks in a row.

    Thanks for your e-mail address I certainly will let you know if I need help and I will check the Medicare Manual as well. I am just concerned that this issue will turn out to be a matter of interpretation.

    Thanks again.

    Karolyn

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