Wiki Procedure with office visit billing

[pkb1969]

I need documentation to prove that billing an office visit on same date of service as a procedure is against coding guidelines unless the office visit is above and beyond and it has a seperate note. I have documentation from Medicare but not from any commercial insurance. I have requested documentation from insurance we are in contract with, but I still have not heard anything. Does anyone have any ideas on how I can find this information documented????

 

[lmartien]

E/M with procedure

I've had some success in going to the commercial payor website and looking at their policies. Most policies for a procedure state the E/M is included in the procedure and they would not expect to see them (the E/M) billed separately in most cases. Good luck!

 

[trudel@smsc.org]

concerning E&M and procedure

Modifiers 25 and 57: A Quick Lesson

January 2nd, 2014


When a patient is seen for a new condition/diagnosis and a procedure is rendered that day, you should report the evaluation and management (E/M) visit with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.

Do not report an E/M service routinely with every procedure. Most procedures include an element of E/M; therefore, the E/M service must be able to stand by itself as a truly significant and separately identifiable service to append modifier 25 appropriately.

For Medicare and other payers (check with your individual private payers for guidance), you should append modifier 57 Decision for surgery—rather than modifier 25—if the E/M service prompts the decision to render a major procedure (defined by Medicare as a procedure with a 90-day global period) within 24 hours of the E/M service. Modifier 25 is appropriate when an E/M service is provided on the same day as a minor procedure (defined by Medicare as having a 0-day, 10-day, or “xxx” global period).

 

[MarcusM]

http://www.aaos.org/news/aaosnow/oct10/managing1.asp gives some good examples of E & M with a procedure. And most commercial insurance plans follow CMS guidelines. The key is to have good pertinent documentation that supports medical necessity.