Wiki OV with Procedure-same visit decision

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glamblondie7

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Some of my doctors work in an urgent care facility, where they see the patient, decide they need a procedure and do the procedure that same day. Can they bill OV (since they needed exam to decide on the procedure). They did not know they were going to have a procedure prior to since it's walk in urgent care. Therefore, can they bill OV and procedure with same diagnosis? eg. A 10060 (simple I & D) is decided upon and done same visit.
 
Just because the decision to perform the minor surgical procedure was not done prior to the appointment does not mean that you can charge an office visit with the procedure.

Per CMS

If the procedure is defined as a minor surgical procedure, the decision to perform it is INCLUDED in the payment for the procedure and should not be reported separately as an E&M service. If the service is UNRELATED to the decision to perform the minor surgical procedure it is separately payable with a 25 modifier. The fact that the patient is "new" is not sufficient alone to justify reporting an E&M on the same date. If the provider is performing a service over and above what is involved in the decision to perform the procedure such as ordering xrays, physical therapy, etc. the E&M service MAY be payable.
 
well I have a doctor who is always really on top of his coding who swears to me that the CPT guidelines language has changed since 10 years ago and that you can do both because you "need the exam to decide if procedure is needed and what procedure is best/needed" ...I do not have a copy of the AMA cpt right now to view those guidelines because unfortunately our office ordered Optum ingenix. Thoughts? Or does anyone know the best resource for guidelines online that are free?
 
The language in the 2013 CPT book for modifier 25 is: "It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed...."

This is consistent with Medicare's policy that the decision to perform minor surgery is included in the payment for the surgery.

You'll get as many interpretations of these guidelines as there are coders in the world. :)
 
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