I have a PA and a physician from the same group seeing the same patient on the same day. The PA does the E/M portion and the physician does a facet joint injection. Can they be billed separately or should I bill under the physician both the E/M (with 25 mod) and the injection? Also, same goes with 2 PAs seeing the same patient on the same day for different injections. Is that billable? Would someone please direct me to a good resource for these instances? Thanks.
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Wiki 2 providers/2 visits - same patient/same day...billable?
- Thread starter jvaughn5
- Start date
dwaldman
True Blue
The claims processing manual and the NCCI policy manual for medicare services were the two resources that I think you cou obtain some helpful information. The confusing thing about your question is you did not state if was an establlished or new patient. To me, if was an established patients and they were coming in for a facet block there would be no separate E/M charge. If they were a new patient I would assume the physician would have to be the one seeing the patient not the PA.
http://www.cms.gov/manuals/downloads/clm104c12.pdf
http://www.cms.gov/nationalcorrectcodinited/
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.
Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
Procedures with
http://www.cms.gov/manuals/downloads/clm104c12.pdf
http://www.cms.gov/nationalcorrectcodinited/
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.
Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
Procedures with
Thanks for the info. To clarify the situation, an established patient is scheduled for an injection with the physician on the same day the patient is scheduled to see the PA for an E/M visit (but for the same dx). If the injection was planned, there is no need for the E/M, but the practice is wanting to bill that way. I need to show them that this is not correct and haven't been able to find any resources to provide them. They are also scheduling the same patient on the same day with either a physician and a PA, 2 PAs, or 2 physicians to do different injections. That doesn't seem right to me either, but again, I need to provide evidence that it is not correct. Any suggestions? 
molivier
Networker
2 providers/2 visits
I would be careful about making rules about E&M on the day of procedure, because if the documentation supports the E&M service it is billable with a 25.
Here is our carriers E&M manual- Look at pages 12-17 for clarification
http://www.trailblazerhealth.com/Publications/Training Manual/EvaluationandManagementServices.pdf
Hope that helps!
Michele
I would be careful about making rules about E&M on the day of procedure, because if the documentation supports the E&M service it is billable with a 25.
Here is our carriers E&M manual- Look at pages 12-17 for clarification
http://www.trailblazerhealth.com/Publications/Training Manual/EvaluationandManagementServices.pdf
Hope that helps!
Michele
dwaldman
True Blue
http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
Here is another resource that you can share with them regarding the use of the 25 modifier.
Here is another resource that you can share with them regarding the use of the 25 modifier.
dwaldman
True Blue
After reviewing the definition of the 25 modiifer. I think what you need to point out to them is that appropriate use of the 25 modifier is following the descriptor of the modifier. It says
"BY THE SAME PHYSICIAN"
so it would be incorrect reporting the 25 modifier on the PA visit.
Below is from Medassets.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
"BY THE SAME PHYSICIAN"
so it would be incorrect reporting the 25 modifier on the PA visit.
Below is from Medassets.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.