I have a doc that does ligation of a hemorriod and several occasions for a patient. He adds an E/M with each subsequent treatment. I'm usually under the assumption that when a person comes in knowing ofa procedure that you can't bill out the E/M. But my doc is doing a COMPLETE E/M that documented. Am I wrong to think that I should NOT be billing it out?
I wanted to expand on the reference Pam made...E/M's aren't automatically bundled into minor procedures when they're on the same day...see below for NCCI's exceptions. In the situation you mentioned, I would not recommend biling an E/M, unless other problems unrelated to hemorrhoids are clearly evaluated and treated (listed in the HPI and MDM at minimum, and the organ system pertaining to the problem should be covered in the exam). Without that, you can't really justify billing a "significant/separately identifiable" E/M service.
Also keep in mind that many commercial and Medicaid payers don't follow Medicare's rules to the letter. For example, some commercial payers may use NCCI edits to deny certain services as bundled, but the criteria required to bill a separate E/M isn't as strict as NCCI's policy manual indicates - they may only use CPT guideline definitions, which make no mention of minor surgical procedure global periods at all. Check with the payer to find out more about their policies. Hope that helps!
"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 a global surgery indicator of “XXX” are not covered by these rules. Many of these “XXX” procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding."
