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Thread: What is above & beyond when it comes to e/m visit & a procedure?

  1. #1

    Default What is above & beyond when it comes to e/m visit & a procedure?

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    Who decides whether or not the E/M was above and beyond the procedure that was performed the same day? In our office we see many new patients with a complaint of changing moles. Our providers document all the necessary information for the E/M and in most cases skin biopsies will be performed on the same day. One of our private payers is stating that if the patient's complaint resulted in a procedure, then an E/M visit cannot be billed. Our doctor feels that the taking of the history, current medications, examining other affected areas all represent the E/M. The private insurer stated that all surgical procedures include some E/M and that is why a seperate E/M cannot be billed. I need to know what exactly surgical procedures include along with how or who determines whether or not the provider went above and beyond the procedure performed, therefore billing an E/M? Also, does the CPT surgical package only pertain to major surgery? Regardless of the answer, where is that information at so I can show my doctor? Thanks!!!

  2. #2
    Join Date
    Apr 2007
    Central Arkansas


    I work for a private payor in Arkansas and our policy states for a new patient we pay the E&M even if it resulted in a procedure since the physican does have to spend more time with someone they have never seen. However, if the patient is established, and if the only thing done was have a mole removed from the arm. Then no the doctor will not get paid additional payment for the E&M according to our P&P, and every payor is different. On the other hand, we follow medicare guidelines on most things, but we don’t have to follow CCI.

    When I'm reviewing documentation for an additional payment for the E&M with -25, above and beyond it would have to be in the documention as a full body exam even if the only procedure done was the mole. I don't except circled documenation or it is denied for insufficent documentation. It also has to be leadgable writing and national abreveations if the doctor uses them or the e&M is denied.

    What I seen some of the provider's do is have the patient come in one day for the visit and another day for procedure, but that results inconvient health care, and if I was the patient I wouldn't return just because the doctor wanted additional payment that they don't deserve. In addition, the staff to pull chart print off a fee ticket, pay nursing staff to check patient in, and then of course the highest cost would be the time in the exam room. Which this would result in more out of pocket for the doctor do it this way, and inconvient for the patient. Here's the factor when only a procedure is done the RVU payment includes the exam, lights, nurse etc. that is included with the procedure payment.

    The best way is to ask your self does the documentation support a procedure and a "separtely identifiable E&M". For a clearer example, the patient comes in to have a mole removed or biopsied and after the procedure is performed the patients mentions his blood presures has been elvated at home for seveal weeks. Maybe the physician will just give an Rx for the HTN or possible draw some labs. In this case, the patient would be willing to make 2 visits for 2 separate problems. One to have mole removed and one to evaluate HTN. Although, I'm assuming this is a derm clinic and probably would refer him to his PCP for the HTN, but for a derm doctor to be above beyond would constitue for the full body exam in addition to procedure on the same day. Nonetheless, this is a very fine line and depends highly on the documentation.

    In addition by charging for an E&M with -25 and procedure on the same day, and if there is no documentation to support both charges this fraud and/or abuse. It could eventually result in recoupment from payor or fines and possible imprisonment.

    I hope i was able to shead a little light on the confusion of when you can and can't bill an E&M w/-25 on the same day of procedure. If i can be anymore of assistance I will be glad to help you understand correct coding.


    Jennifer Cooper, RHIT, CPC

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