EM Coding Alert

Question: Is there any way to get paid for an established office visit when a patient comes in for a PSA screening? I know we can’t bill for the PSA that is determined by an outside lab, but I thought we could get some reimbursement.

Massachusetts Subscriber

Answer: You should report 36415 (Collection of venous blood by venipuncture) if your practitioner only performed a blood draw.

If he also performed an office visit for a particular problem during the same encounter, then code the E/M service as well using the appropriate office visit code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...).

Alternately: If your physician also performed a screening rectal examination, bill only for the screening visit using G0102 (Prostate cancer screening; digital rectal examination). However, do not report separately a digital rectal examination (DRE) if the provider is also performing a complete E/M service as above on the same date. Reimbursement for the screening DRE (G0102) is bundled into payment for a covered E/M service (99201-99456 and 99499), when the provider furnishes the two services on the same day, states the Guide to Medicare Preventive Services.

Why:  Medicare is differentiating between the “screening” patient and a problem-oriented patient. Since a screening patient comes in for a DRE with no symptoms, the argument is that there should not be a problem-oriented E/M service billed on the same date.

Don’t think that appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) can release you from that bundle, even if the E/M service is unrelated to the DRE. Modifier 25 on the E/M service is not allowed when attempting to add the DRE to the claim.