Wiki Significant, separately identifiable EM

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AprilSueMadison

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What can I give or say to my providers to help them understand that just because they SEE a patient or just because they FEEL like they did an office visit.....doesn't mean they can actually bill out an office visit and a procedure?

Any suggestions?
 
I use information from my Medicare MAC as they often have examples.
The CMS NCCI coding manual states "the decision to perform the procedure is insufficient to support a separate E&M service with a minor procedure."

The following information is good information also from one of my conferences I attended in the past.

To determine if the additional EM service with Modifier 25 is appropriate, consider if your answer is yes to one of the questions below:

?
Could the complaint or problem stand alone as a billable service?
?Does the complaint or problem have a different diagnosis?
?Does the EM service rendered and the documentation of the service meet the established EM guidelines?
?If the diagnosis is the same as the scheduled visit, were the services outside of the typical pre- or post-operative work associated with the procedure?​

It is important to note that reporting an additional visit with a preventive care code requires that the components for the reported level of EM service be met. An incidental problem that is of very low complexity and requires little to minimal decision making would be considered incidental to the preventive care E/M service.
 
So the following is from Medicare regarding E/M and NCCI edits..

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ?new? to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological
Click to expand...

The example is what concerns me. Medically reasonable to me sounds as if they need to document something showing it is medically necessary. If they don't document anything extra, saying perhaps patient is experiencing forgetfulness, they don't have an E/M correct?

My Derm example is below
https://www.aapc.com/memberarea/forums/showthread.php?t=108160

I'm trying to get everything I can together to show the doctors why they don't always qualify.
 
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