Wiki Calculating Risk for Minor Procedure Performed on Same Day

[deajsharichardson]

When it comes to in-office, same day procedures being performed during an E/M, are you allowed to factor the risk of the procedure into Element #3 (The risk of complication and/or morbidity or mortality of patient management)? For example, if a patient presents with knee pain and the provider’s management option to treat that knee pain was to give the patient an arthrocentesis injection, risks and benefits were reviewed and documented, can you count the risk of the injection towards the medical decision making of the encounter for the E/M (moderate risk for a minor surgery with identified risk factors), even though the procedure is being separately reported by the same provider?

99213-25, 20610 – with the procedure being separately billable, can we still factor the risk of the procedure into Element #3 of medical decision making for the E/M? Giving the patient an injection during the encounter drives their risk up because there is a risk of side effects, etc.

Or would this be considered double—dipping in some way?

 

[flowergrl]

I have this same question. I code Ortho, and this is a serious gray area. Do you count the injection risks discussion for the E/M? And also, which E/M level do you choose?

For example, patient has long time knee pain, more than a year chronic with more pain recently (Moderate level). Provider looks at no imaging, no outside notes, just does an exam in office (Minimal level). They have long discussion on treatment options from rest, PT, bracing, to injection -pt doesn't want surgery. Does the 99214 "decision regarding minor surgery with identified risk factors" mean risk factors of the knee injection itself (because all procedures have risk factors), or does it mean patient specific risk factors (such as diabetes, opposite leg amp, long term anticoagulation, autoimmune disease, etc.) that makes this procedure risky for THIS patient?

If we consider "with or without risk factors" to be procedure specific, then if the provider documents "injection risks and benefits discussed" will apply to all joint injections and will always change the level from 99213 to 99214 (for example). But if considered patient specific, the provider would need to document that THIS patient has XYZ that makes this procedure especially risky for a 99214... or the patient doesn't have any special risk factors and is a normal healthy patient 99213 (minor surgery without risk factors).

There has been the argument that it does say " with identified patient or procedure risk factors" and the "or" is the key word. That means it applies to both patient and procedure, which would mean if the provider documents that risks and benefits were discussed of the injection, the level is a 99214.

 

[natashalage]

hello,
I am not an expert, nor a guru. I am still learning but here is my thought. I read a copy from NCCI and heard that when pt has for a minor procedure 0-10 global days, some elements of E/M are included into the procedure and therefore, there is no warrant for E/M-25 unless there is a separately identifiable service or unrelated condition that is discussed, treated, monitored etc. Same rule applies to even New patient. When pt comes for a knee pain and MD does injection and then pt mentions a bothersome pain in the shoulder and MD assesses it, makes a plan etc, then it's clear to me- E/M-25. What is not very clear is when we have a big note and all what is documented -about knee pain. What can be helpful is when MD puts a time statement like ' I spent 25 min on reviewing the records, writing orders and this time is excluded from the time spent on a procedure.."(I don't remember exact phrase) and still the documentation must support a separately identifiable service. As for the Moderate Risk, you also need to find level for Dx and Data in order to arrive to E/M level. I hope it's not 99214.

 

[jkyles]

hello,
I am not an expert, nor a guru. I am still learning but here is my thought. I read a copy from NCCI and heard that when pt has for a minor procedure 0-10 global days, some elements of E/M are included into the procedure and therefore, there is no warrant for E/M-25 unless there is a separately identifiable service or unrelated condition that is discussed, treated, monitored etc. Same rule applies to even New patient. When pt comes for a knee pain and MD does injection and then pt mentions a bothersome pain in the shoulder and MD assesses it, makes a plan etc, then it's clear to me- E/M-25. What is not very clear is when we have a big note and all what is documented -about knee pain. What can be helpful is when MD puts a time statement like ' I spent 25 min on reviewing the records, writing orders and this time is excluded from the time spent on a procedure.."(I don't remember exact phrase) and still the documentation must support a separately identifiable service. As for the Moderate Risk, you also need to find level for Dx and Data in order to arrive to E/M level. I hope it's not 99214.

I agree. Modifier 25 would be appropriate if the doctor had no idea they would be performing a procedure. I've heard far more experienced coders than me call this the "Oh by the way" visit. For example, the patient made an appointment for an unrelated problem and during the visit said "Oh by they way, my knee has been killing me for two months" it would make sense.

But if a patient makes an appointment because of chronic knee pain, the doctor was (or should have been) already thinking about a joint injection.

 

[csperoni]

There seem to be 2 real questions/issues here:
1) Is the E/M significant and separately identifiable?
2) IF yes, can you count the risk of the injection toward your MDM leveling?

It is certainly possible to have a significant and separately identifiable E/M the same day as an injection. Historically, this has been overused/abused/misunderstood. As previously mentioned, for a patient being treated for an existing knee pain (and no other problem) it is unlikely to have a significant and separately identifiable visit. Look at the note. Cross out all the information and work that is part of evaluating the patient prior to an injection. Is the separately identifiable information left SIGNIFICANT? Probably not if the clinician has been treating this problem. If during a previous visit, the clinician determined a knee injection would be the next step if not improved, then definitely not. If during this visit, the problem was determined to have worsened, there was a discussion or possible surgery and risks, additional PT, etc., and then after shared decision making, the patient chose the injection, then yes, that's an E/M with -25.
Here's what the 2021 AMA guideline states about it:
The physician or other qualified health care professional may need 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. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

Regarding issue #2, if there actually is a significant and separately identifiable E/M, can you count the risk of the procedure toward your MDM? While this is not explicitly stated in the AMA 2021 guide, I interpret the existing advice as you may count the risk. Here's my logic:
1) It is specified if you are performing or interpreting a diagnostic test or study, that is not counted toward MDM. It does NOT state procedure.
2) Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
This is all talking about the risk of the actual treatment/management. The risk doesn't change whether or not you are the clinician performing the procedure.
3) Clearly, you count risk of a surgery the clinician will be performing. No one is questioning whether you count that risk. Even if it were the same day (with -57). To me, the same reasoning would apply here.

Summary: IF the E/M is billable, then you can count the risk of a procedure being performed by the same clinician.

 

[nolanspade]

There seem to be 2 real questions/issues here:
1) Is the E/M significant and separately identifiable?
2) IF yes, can you count the risk of the injection toward your MDM leveling?

It is certainly possible to have a significant and separately identifiable E/M the same day as an injection. Historically, this has been overused/abused/misunderstood. As previously mentioned, for a patient being treated for an existing knee pain (and no other problem) it is unlikely to have a significant and separately identifiable visit. Look at the note. Cross out all the information and work that is part of evaluating the patient prior to an injection. Is the separately identifiable information left SIGNIFICANT? Probably not if the clinician has been treating this problem. If during a previous visit, the clinician determined a knee injection would be the next step if not improved, then definitely not. If during this visit, the problem was determined to have worsened, there was a discussion or possible surgery and risks, additional PT, etc., and then after shared decision making, the patient chose the injection, then yes, that's an E/M with -25.
Here's what the 2021 AMA guideline states about it:
The physician or other qualified health care professional may need 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. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

Regarding issue #2, if there actually is a significant and separately identifiable E/M, can you count the risk of the procedure toward your MDM? While this is not explicitly stated in the AMA 2021 guide, I interpret the existing advice as you may count the risk. Here's my logic:
1) It is specified if you are performing or interpreting a diagnostic test or study, that is not counted toward MDM. It does NOT state procedure.
2) Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.
This is all talking about the risk of the actual treatment/management. The risk doesn't change whether or not you are the clinician performing the procedure.
3) Clearly, you count risk of a surgery the clinician will be performing. No one is questioning whether you count that risk. Even if it were the same day (with -57). To me, the same reasoning would apply here.

Summary: IF the E/M is billable, then you can count the risk of a procedure being performed by the same clinician.

Hello - off subject - I'd like to pick your brain on the logic you use (love it) - if one says and the other doesn't, then one is and the other isn't. I've had disagreements with colleagues (outside of my team) about this nuance when it comes to lamis and when it comes to PT codes (supervision vs one-on-one, et al). my email is nolan.spade@rothmanortho.com