We have an outsourced billing co that does our surgery coding an payment posting. They also keep us in the loop of changes and/or heads up on billing for the clinic. They recently stated that MC has clarified the Evaluation and Management on the same day as a Minor Surgical Procedure as seen below:
Evaluation and Management on Same Day as a Minor Surgical Procedure
Chapter 1, Section D
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for this procedure
Revison date (Medicare):1/1/13
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 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 on the same date of service as a minor surgical procedure.
Our Billing Co initial interpetation of this is below:
Although Medicare has clarified that an E&M service on the same date
as a minor surgical procedure is included in the payment for the minor surgical
procedure, the criteria for billing the E&M separately from the minor surgical
procedure has not changed. If a â€śsignificant and separately identifiable E&M
service UNRELATED to the decision to perform the minor surgical procedureâ€¦â€ť
is performed, then the E&M service is separately reportable with a 25 modifier.
We believe that this is more of a clarification than a change in policy. We strongly
suggest that the documentation for any E&M service billed with a minor surgical
procedure must contain a high level of detail to ensure that the medical necessity
of the E&M service passes the â€śSignificant and Separately Identifiableâ€ť litmus test
and that the medical decision making includes more than just the decision to
perform the minor surgical procedure.
Please note that the fact that a patient is â€śnewâ€ť does not constitute an
exception to this policy.
No suprise, our doctors are not happy with this as it affects all of our steroid injections. Which in the clinic are numerous. One of our Drs asked the question that if one or more of the following were included in the chart notes, he felt an E&M per the wording above was acceptable: Xrays were taken, PT was ordered or work restrictions given the patient,
This was passed along to our billing co for their feedback. See feedback below:
If the Dr orders PT and/or puts a patient on work restrictions, you would be justified in adding the 25 modifier and billing to Medicare (and all other carriers). As for the x-ray, if the Dr addresses the x-ray and any associated pathologies in the Plan/Assessment portion of the E&M, then you can add the 25 modifier and bill to Medicare. However, if the x-ray is negative for any pathologies and the plan simply states:
â€śx-ray is negative for <fill-in>. Patient will be given a depomedrol injection for pain. Will return in 2 weeks for further evaluationâ€ť
Then the 25 modifier would not be appropriate.
Quite simply put, I am not sure this is what MC is trying to accomplish, which is NO E&M code with an injection. Of course I "get it" that if you are addressing a whole different problem the 25 modifer would apply. But if a new patient does not qualify for an E&M code with an injection, I am not sure simply reading Xrays (which we have for almost every injection) ordering PT or putting the pt on work restrictions would qualify for an E&M code either.
Anybody have any thoughts on this? To code or not to code and E&M with an injection.. that is the question
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