Wiki E/M with cpt code 17250 billed

[ericaygo93]

Hello, looking for insight to the billing of procedure 17250 for umbilical cauterization along with E/M visits such as 99213 or 99214. I've tried to review the global surgery packet but did not see an example of why the billing would not be permitted when it was medically necessary. In my example, what is the proper billing practice if the patient has had to have this completed multiple times within a months time. The latest claims E/M was denied by BCBS, despite submitting records showing the support of modifier 25 attached to the E/M. Any info would be appreciated. Additional note is more than one visit with cauterization was performed within the 10 day rule and one outside of the 10th day.

 

[Cynthia Hughes]

Hello, looking for insight to the billing of procedure 17250 for umbilical cauterization along with E/M visits such as 99213 or 99214. I've tried to review the global surgery packet but did not see an example of why the billing would not be permitted when it was medically necessary. In my example, what is the proper billing practice if the patient has had to have this completed multiple times within a months time. The latest claims E/M was denied by BCBS, despite submitting records showing the support of modifier 25 attached to the E/M. Any info would be appreciated. Additional note is more than one visit with cauterization was performed within the 10 day rule and one outside of the 10th day.

An E/M for follow-up is included in the global period of the procedure. For payers that align with Medicare this even includes complications other than a complication requiring surgery in an operating room. If the E/M were for an unrelated reason, modifier 24 might override the global period edit but this appears to be a return for a more extensive or repeat procedure (i.e., a related service). Some payers will bundle a related E/M on the date of any minor procedure as included in the preservice work value of the procedure. However, when significant E/M work is required to determine a diagnosis and arrive at a decision for a procedure, modifier 25 is appropriate.

The separate billing of an E/M as significantly above and beyond the preservice work of a procedure is subjective so if the physician feels that the documentation supports both the required components and medical necessity for an E/M, you can appeal the denial. It may be useful though to seek an independent internal or consultative review of the records prior to filing an appeal.

I hope this is helpful.
Cindy