Billing for E/M on the Same Day as Procedure is Not Affected by Number of Diagnoses
Published on Fri Sep 01, 2000
Some general surgeons and coders are uncertain about whether and when to bill a visit on the same day as a procedure, for example, when the procedure and visit both relate to the same problem. In practice, this often means that two different diagnosis codes should be used and that a single diagnosis code is appropriate only if the diagnosis is a sign or symptom that is not repaired or identified by the ensuing procedure.
The underlying issue, however, should not be the second diagnosis. The number of diagnoses is not the determining factor, says Kathy Pride, CPC, CCS-P, a coding and reimbursement specialist with Martin Memorial Medical Group in Stuart, Fla. Its whether you can prove the procedure wasnt planned or scheduled. If two diagnoses arent available, the surgeons notes should support the fact that only after the visit did the need for the procedure arise, Pride says.
Billing Criteria for Visits
Two factors determine if the visit may be charged: (1) Did the visit lead to the procedure being performed? and (2) Was the visit significant?
If the procedure is preplanned and the visit is just a routine check, no evaluation and management (E/M) service should be charged. But if the history, examination and medical decision-making were significant and directly led to the decision to perform the procedure, it should be payable.
For example, a primary-care physician (PCP) requests a consult for an 86-year-old patient with a cystic thyroid mass. The surgeon reviews the PCPs workup and data, assesses the patients suitability for surgery and decides to aspirate the cyst the same day.
Because the visit was significant and directly led to the decision to perform the procedure, it should be payable, but only if the documentation clearly indicates the link between the visit and the decision to aspirate the cyst. The documentation has to indicate that the surgeon did not know the procedure necessarily would be performed, Pride says. It all depends on what the surgeon intended to do when the patient arrived.
In this instance, a second diagnosis is sufficient documentation to indicate to the carrier that the physician examined the patient before determining a course of action. The consult, therefore, would be coded 9924x-25 (the appropriate consult code with modifier -25 [significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] attached), and would be linked to ICD-9 code 784.2 (lump in neck). The aspiration of the cyst is coded 60001 (aspiration and/or injection, thyroid cyst) with ICD-9 code 246.2 (cyst).
The number of diagnoses used is not the issue; rather, it is what they reveal about the patient encounter. Clearly, if the physician had [...]
