MHira
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Is it ok to send both E/M and surgical service together if no separate identifiable non-surgical service is given at the time of service?
Is it per payer contract, which can allows both together(E/M and Surgical codes) or E/M code can supersede Surgical code even though it is truly surgical visit?
In my understanding so far
Visits by the same physician on the same day as a minor surgery are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
• The “unless” clause is important. It allows you to report(and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is significant” and “separately identifiable”
• In practical terms, this means: The medically necessary E/M service must “go beyond” the usual E/M component included as part of the minor procedure.
• Documentation must support both minor procedure and separate, independent E/M service(e.g., the E/M documentation must “stand alone”). Although it's not required, best practice is to separate E/M note from the procedure note.
Is it considered noncompliant if both surgical and E/M codes goes together without documentation support for both being done at time of service?
Thanks and appreciate knowledge support!
Is it per payer contract, which can allows both together(E/M and Surgical codes) or E/M code can supersede Surgical code even though it is truly surgical visit?
In my understanding so far
Visits by the same physician on the same day as a minor surgery are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
• The “unless” clause is important. It allows you to report(and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is significant” and “separately identifiable”
• In practical terms, this means: The medically necessary E/M service must “go beyond” the usual E/M component included as part of the minor procedure.
• Documentation must support both minor procedure and separate, independent E/M service(e.g., the E/M documentation must “stand alone”). Although it's not required, best practice is to separate E/M note from the procedure note.
Is it considered noncompliant if both surgical and E/M codes goes together without documentation support for both being done at time of service?
Thanks and appreciate knowledge support!