Wiki Modifier -25 on E/M when billed w/diagnostic procedure on same DOS

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nomie7

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I am in urology specialty. Often times we have a patient come in for a scheduled cystoscopy (diagnostic procedure), and a lesion is discovered, and/or the provider decides to pursue surgery after the cystoscopy for a variety of reasons; sometimes a transurethral resection of prostate. Anyhow, we have been told before that it may be appropriate to bill an E/M on the same date as the cystoscopy if the plan changes and the other requirements of the E/M have been met such as the Hx and Exam level. I struggle with this concept especially given that it is a diagnostic procedure in nature and that it would be expected to gain information and do something with that information afterwards. Does anyone have any thoughts on this situation and how it should be billed. Thank you.
 
I don't know the answer -

But isn't the cystoscopy done in an OR type setting? Not done in the office? If that is the case, where would you pull the extra information for a history, exam, and mdm from?

I guess the MDM from the results of the test. But the history and exam? I would think you couldn't code an additional E&M.

If the patient comes back for results and a decision for surgery is made, yes, I believe you could code the E&M. But I don't think that was your question.

But at least for me, it doesn't seem like you would be able to code an additional E&M.
 
Thank you for your input. We do cystoscopies in the office setting all of the time. Every once in a while it is done in the OR due to extenuating circumstances.
 
Most procedure codes like what you describe includes some E&M, but usually not enough to bill a new patient evaluation. The reimbursement supposedly calculates this as part of the total compensation. Modifier 25 states it must be significant to bill in addition to a surgical procedure.
 
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