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  
0 Votes - Sign in to vote or comment.

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.


Latest articles:  (any category)

How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —
November 18th, 2020 - Raquel Shumway
Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.
Cross-A-Code Instructions in Find-A-Code
November 18th, 2020 - Raquel Shumway
Cross-A-Codeis a toll found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
COVID Vaccine Codes Announced
November 11th, 2020 - Wyn Staheli, Director of Research
On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
CMS Expands Telehealth Again
October 20th, 2020 - Wyn Staheli, Director of Research
On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.
Significant COVID-19 Code Changes as of October 6
October 8th, 2020 - Wyn Staheli, Director of Research
Significan COVID-19 Code Changes as of October 6



Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2020 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association