Wiki Evaluation & Procedure billing

[suebrock17@gmail.com]

We evaluate a patient and determine a lesion must have a biopsy. We perform the biopsy during that visit. The patient has no other concerns. Does Medicare now determine we should not be reimbursed for the evaluation? We are only to be reimbursed for the procedure? It does not matter if the patient is new or established. Is this correct? It seems unfair to the physicians that their time to evaluate is no longer reimbursable.

 

[hudiknight]

E/M with minor procedures Medicare rule

That is correct. Big hit on E&M visit codes. Try using history of skin cancer, chronic solar damage and all other findings. Sometimes it works, but not always. They will ask for records anytime an E/M is used with cryo, biopsy.

 

[mitchellde]

Please do not try to get paid for an E&M by throwing additional dx codes on the claim!
If the documentation shows a relevant and significant exam is performed in addition to the biopsy then you can appeal with the documentation and get paid. the evaluation of the lesion is considered part of the procedure. You need significant examination outside of that to justify the visit. In addition the additional hx/exam/MDM must be relevant to the patient cc or presenting condition. CMS is very aware that most providers use templates and have very thin documentation outside of the presenting problem that can justify the E&M. Remember the parts of the hx/exam/mdm that are a part of the procedure cannot be counted toward the visit level. This is what makes it very hard to be able to justify the E*&M and bill it with the 25 modifier.

 

[JesseL]

does this apply to injections as well? 11900 or 96372?

Insurances pay more for a level 2 e/m visit than they would for 11900, I think we get reimbursed more for a level 1 e/m visit than 96372.

 

[mitchellde]

you cannot substitute a visit level for a procedure just because it pays more. You must bill for the code(s) that are supported by the documentation.

 

[JesseL]

you cannot substitute a visit level for a procedure just because it pays more. You must bill for the code(s) that are supported by the documentation.

What if a expanded problem focus history and exam was taken, diagnosis keloid and plan of treatment is kenalog injection? can we bill 99202 with modifier 25 and 11900 or only 11900?

I'm asking because I'm assuming 11900 has some component of e/m like every other procedure if I'm correct?

Same for IM injections?