Can we bill a low level E/M with every procedure?

June 1st, 2015 - Codapedia Editor
Categories:   Coding   Compliance   Evaluation & Management (E/M)   Modifiers   Primary Care|Family Care  
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Can’t we bill a low level E/M with every procedure?

No!  

Medicare says this:

Per CCI (chapter 11, Letter R.): “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.

Physicians who think they are entitled to a low level E/M with every procedure are likely to be audited by their Medicare carrier or MAC.  There are a few problems with this practice:

•    It is not medically necessary

•    CMS has included the payment for evaluating the site, consent, and post op instructions in the payment for the procedure

•    It increases the percentage of low level visits in the provider’s profile, which attracts the attention of the payer

•    It drastically increases audit risk

Take for example, the Podiatrist who visits a nursing home to provide nail care.  At each visit, he billed the lowest level nursing home code, and the procedure.  He probably thought he was flying under the radar by billing such a low level service, but he was actually waving a red flag.  He documented these visits on a form that consisted of mostly checking history and exam elements.  The common diagnoses were on the form, and he checked them.  Then, he documented the procedure.  All of the visits looked exactly the same.  There was no new medical decision making.  If the patient’s status had changed, requiring an E/M service, it couldn’t be determined from these notes.

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