Same-day E/ M and Office Procedure:
Yes,
You Can!
Documentation and proper modifier 25 application is essential.
Providers generally learn from their billing and coding
staff that reimbursement for office procedures includes the immediate pre- and post-procedure
management of the patient. In my experience, providers sometimes “over learn”
this lesson, and conclude that it is never possible to receive separate reimbursement
for an evaluation and management (El M) service and an office procedure at the
same encounter. To capture all
appropriate revenue, it is important to know what is included in the global
package for office-based and surgical procedures, and understand when an El M service
and an office procedural service can be billed in the same encounter, with
appropriate documentation.
What's
Included in the Global Package
The American Medical Association’s (AMA’s) 2012
CPT'Pr0fi'ssi0nal Edition codebookdefines the following as “always included” in
the global fee for a surgery or procedure:
- Subsequent to the decision for surgery (procedure), one related El M encounter on the date immediately prior to, or on the date of, the procedure
- Immediate postoperative (post-procedure) care, including talking with the family and other physicians
Regarding diagnostic procedures, CPT' further specifies,
“Followup care for diagnostic procedures includes only that care related to recovery
from the diagnostic procedure itself. Care of the condition for which the
diagnostic procedure wasperformcd or of other co-existing conditions is not
included.” [emphasis added]
Medicare’s definition of the global package is broader than
the AMA’s, but clearly states, “Services not included in the global surgical
package are as follows:
- The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery [procedure]
- Treatment For the underlying condition or an added course of treatment, which is not part of normal recovery from surgery
- Diagnostic tests and procedures, including diagnostic radiological procedures.”
Common
Scenarios for Separate Services
With a clearer understanding of what is meant by “global
package” (and what counts as counseling for El M services), you can identify
two common scenarios where billing for an El M at the same encounter as a
procedure is legitimate—provided there is the appropriate documentation in the
medical record.
The procedure must not have been the reason for the visit,
and documentation must reflect the medical decision making (M DM) based on the
evaluation undertaken at that visit that preceded the recommendation of a
specific procedure. Documenting the options offered to the patient (with the
eventual choice of the performed procedure) strongly supports billing an El M
and procedure together.
Example: A postmenopausal woman is seen for an urgently
scheduled appointment in her gynecologist’s office because she noticed blood in
her underwear. Upon examination, the source of the blood appears to be the cervix.
The gynecologist offers the patient a choice of scheduling a pelvic ultrasound
or undergoing immediate endometrial biopsy (EMBx). The patient chooses an
immediate EMBx.
The proper coding in this example is 58100 Endometrial
sampling (biopsy) with or without endocervical sampling (biopsy), without cervical
dilation, any method (separate procedure) and the appropriate level El M
service (e.g., 99212-99215, “Qffice or other outpatient visit for the
evaluation and management of an established patient”) with modifier 25
Significant, separately identifiable evaluation and management service by the
same physician on the same day of the procedure or other service appended.
Note that it is not unexpected that an EMBx was going to be
performed, but the documentation supports that it was not planned prior to the
El M service.
Remember, the global payment for any procedure includes
pre-procedure explanation and preparation, as well as post-procedure instructions,
restrictions, and precautions, plus information about what to expect during the
recovery period. It does not include the MDM that follows as a result of the
procedure performed. That work is separate, and if documented clearly,
separately billable. Documentation should be specific as to the time involved
and the content of the counseling. In addition to providing a reasonable narrative
of “counseling and coordination of care” that follows the interpretation of the
results of an office procedure, it is important to include in the documentation
a statement such as, “Exclusive of the procedure, greater than 50 percent of the
visit was spent in counseling and coordination of care. Total visit time: 15
minutes.”
Example: A patient undergoes cystoscopy in the physician
office because of bladder pain syndrome. Multiple fields of glomerulations are
noted. Immediately following the procedure, the physician counsels the patient on
the pathophysiology of interstitial cystitis (IC), as well as posible treatment
options. After discussion, the patient chooses to start Elmiron® (Pentosan
polysulfate). She will follow up in six weeks.
In this case, proper coding is 52000 Cystouret/Jroscopy
(veparateprocedure) and the appropriate El M service level (e.g., 99211:) with
modifier 25 appended. Documentation must substantiate that the El M service is
both significant and separately identifiable from the El M component included
in the payment for 52000.
Careful and
Deliberate Documentation ls Essential
Although the immediate pre-procedure and post-procedure care
and counseling of the patient is included in the global fee for an office procedure,
other related El M work is not. The immediately preceding evaluation that leads
to the recommendation of an office procedure can be billed on the same day as
the procedure itself. Similarly, counseling and MDM that arise from the results
of a procedure may take place immediately following it and are separately billable. In both cases, careful and deliberate
documentation to separate the work embodied in the two CPT' codes is essential.
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