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EM visit billed with Infusions & Chemo

  1. Default EM visit billed with Infusions & Chemo
    Medical Coding Books
    Hi All,

    Does anyone have a link or reference guide that I can provide to our providers which clearly spells out an EM can only be reported with infusions & chemo when there is medical necessity. Our providers feel they're entitled to an EM reimbursement every time a patient is scheduled for these treatments without supporting medical necessity.
    I don't know how else to convey to them that this is fraud.

    I have two specialties, Renal and Hematology that won't change their codiing behavior and need some concrete guidelines to convince them.

    Please help!!
    Thanks you.

  2. Default
    Please any takers???

  3. #3
    Columbia, MO
    This goes to the logic of the 25 modifier. You cannot charge an E&M when the patient has already been scheduled for a procedure or service since the medical necessity for the procedure has already been determined. If there is a reason to examine the patient beyond the predetermined procedure then you may have an E&M in addition but documentation must clearly reflect an assessment over above and beyond the necessity for the procedure.
    In addition the MCM states that you cannot charge an E&M when the patient comes in for chemo unless it if for reason unrelated to the chemo.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    Thank you Debra!

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