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.
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Chiropractors treat, among other things, issues with the musculoskeletal system. Active therapeutic procedures are accepted as effective ways to treat many common conditions and therefore can be billed and generate revenue for a clinic. Two common CPT codes that might be used in a chiropractic setting include:
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?
Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.
Are you using something other than two-midnight? Here’s why you shouldn’t be. Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has...
Question: If CCM hours/work is to be billed monthly, and CCM tasks are done daily throughout the month, should it be saved until the end of the month to bill, and should each date be billed as DOS in one claim?
Answer: According to CMS, “The service period for CPT 99490 ...
When reporting CCM or TCM codes, you will only get reimbursed for what is allowed. The E/M office visits can be coded in addition but are not interchangeable with CCM codes. You can bill an E/M visit during the time a patient is under Care Management, however, you can’t count time ...
Question: Is there a financial penalty for billing over the allowed amount?
Answer: Yes, if you are submitting claims to a contracted provider, you cannot bill over the contracted amount of your fee schedule. This is called balanced billing. There is also the no-surprise rule that protects insured and non-insured or ...
