Wiki Laceration repair with Emergency EM

[dorinda05]

Can someone please shed some light on billing ER E/M 99284-25 with laceration repair 12031?

We have been advised by our auditor to delete 99284-25 as it is included in the preop work of 12031. I am referring to the AAPC Medical Coding Training 2016 manual that states 10 day minor procedures Evaluation and Management services on the day of the procedure and during the 10 day postoperative period are not reimbursable.... it then goes on to state SERVICES NOT INCLUDED IN THE GLOBAL PACKAGE: INITIAL consultations or evaluation of the problem by the surgeon to determine the need for surgery...for minor surgeries and endoscopies, the Medicare program will not pay separately for an EM service on the same day as a minor surgery unless a significatnt, separately identifiable service is also performed, for example, an initial consultation or initial new patient visit.... Isn't the first time a patient presents to the ER with a particular problem considered an INITIAL visit?

 

[Chelle-Lynn]

The answer to the question comes down to the documentation on the account. A 99284-25 can be billed with as procedure on the same day if the documentation from the provider justifies the use of the modifier 25.

Remember that the use of the modifier 25 states:

When, on the day a procedure or service identified by a CPT® code is performed the same physician performs a significant, separately identifiable E/M service – a service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed – add modifier -25 to the usual procedure code.

In this case you would need to review the medical record to determine if the justification is available.. All procedures have a certain amount of evaluation and management assumed within the care. I would review with the auditor their reasoning for excluding the use of modifier 25 in this case.