Medicare Compliance & Reimbursement

Hint: Don’t forget how comorbid conditions can impact pre-op E/M coding.

Whether you’re an ace at preoperative evaluations or just getting started, they can be confusing, especially when it’s time to choose the right codes for your claims. From knowing how and when to report an evaluation and management (E/M) service separately to when to report ICD-10-CM Z codes, the small details matter.

Take a look at this pre-op primer to boost your coding caliber.

Contemplate the Decision for Surgery When Billing for E/M Services

One common source of confusion has to do with separate E/M billing. For example, let’s say the surgeon sees a patient and schedules an operation based on that visit. When the patient comes back the day before the surgery for a pre-op evaluation, can you bill another E/M even if nothing has changed from that first encounter?

The answer may depend on the payer. For payers such as Medicare that have global surgery guidelines, you must bundle certain services before and after the surgery based on the rules for the appropriate global period.

Under Medicare rules, once the provider makes the decision for surgery, you should not separately bill any preoperative visits related only to the surgery. In other words, the prescreening visits don’t usually present new information that warrant the need for an E/M service.

Exception: If the patient’s situation changes between the first and second visits before surgery, you might be able to make the case for billing another office/outpatient E/M.

For instance, if the patient develops a serious medical condition that is unrelated to the reason for the surgery — but could impact the outcome — the physician may perform additional services that increase the level of medical decision making (MDM). If properly documented, this could allow you to bill a separate E/M visit. An example of this might be the sudden onset of severe symptoms of liver disease like jaundice, abdominal pain, and swelling during a pre-colonoscopy visit. This is a serious condition that could be considered unrelated to the need for a colonoscopy and would therefore require a completely separate E/M service.

Modifier alert: Remember to append 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) when there is a separately billable E/M. Documentation must clearly support the separate service. “We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Consider Comorbid Conditions Before Colonoscopies

Many providers like to perform an E/M before screening colonoscopies, but these visits are generally not billable; however, there is an exception to this rule.

Physicians commonly do screening or surveillance colonoscopies for patients with serious comorbid conditions. They’ll also perform medically necessary evaluations to assess whether the patient is stable enough to proceed, and also to provide the patient with special instructions (such as how to manage anticoagulants, complex diabetic regimen, severe asthma, severe sleep apnea, etc.). In these situations, most Medicare contractors don’t question E/M visits before a colonoscopy.

If there are no apparent requirements for use of such specific codes, chart documentation should make clear the medical necessity for the pre-procedure evaluation, even if the patient has no GI symptoms or disease. In other words, the ICD-10-CM codes in these situations should reflect the comorbid conditions, and the chart documentation should reflect the evaluation of the conditions as well as any special considerations. Such considerations might include management of insulin or diabetes meds, holding anticoagulants etc. Note that if you are reporting the screening Z code, do not submit it as the first code.