Radiology Coding Alert

Question: The physician saw a patient in his office for swelling of the leg that hadn't responded to conservative therapy. He made the decision to perform endovenous radiofrequency ablation. On the day of the procedure, the physician submitted to me an H&P (history and physical) for an established outpatient visit. He already made the decision for the procedure in his office several days prior. I thought a pre-procedure H&P to confirm that the test is necessary and there are no contraindications was included in the RVUs for the procedure itself. Can this H&P be billed on the same day as 36475?

Codify Member

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).

A brief related history, exam, and medical decision making (MDM) is expected and therefore included with payment for the procedure. So in this case, where the doctor is checking necessity and contraindications related to the procedure, you shouldn't report the H&P separately.

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.