General Surgery Coding Alert

Question: Our surgeon performed an endovenous radiofrequency ablation procedure three days after seeing the patient and making the decision for surgery. On the day of the procedure, the physician submitted to me an H&P (history and physical) for an established outpatient visit. I thought that the procedure itself includes a pre-procedure H&P to confirm that the test is necessary and there are no contraindications. Can I separately bill this H&P on the same day as 36475?

Ohio Subscriber

Answer: You’re correct that you should not report the related H&P on the same day as the ablation (36475, Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated).

The procedure requires a brief related history, exam, and medical decision making (MDM), so it’s included with payment for the procedure.

Additionally, 36475 has a 000 global period. According to the Medicare physician fee schedule, 000 means: “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”

For additional information on global period E/M services, including proper use of modifiers, see Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.8: www.cms.gov/manuals/downloads/clm104c12.pdf.