CPT® coding and surgical packes

I work for a billing comapny and it seems that when the doctor submits an E/M
code on the same day as a surgery the E/M code is not being paid.

Example1 99213-25
11900


Example2 99204-25
11100

Is this considered unbundling?
How should the doctors office code this procedure?

re: CPT® coding and surgical packes

There is actually a great article in AAPC's Coding Edge June 2012 that I just read that basically states that documentation should include a clear history, exam and MDM apart from the procedure performed on the same day to report an E/M with modifier -25. If the patient was coming in for the procedure only, you can only bill the procedure code. The decision to perform the procedure must be an unplanned procedure decided during the encounter. If you feel your doctor's documentation for the E/M can "stand alone," I would appeal.

re: CPT® coding and surgical packes

Office Visit and Procedure on the Same Day
By Betsy Nicoletti, CPC

When should a clinician bill an Evaluation and Management (E/M) service and a procedure on the same day?

- When the documentation supports that a significant, separately identifiable E/M
service was provided on the day of the procedure

- When the E/M service is medically necessary to the patient

- When the E/M service is separately documented

- When the documentation meets the criteria (history, exam and medical decision
making) for the level of service billed

Use caution if the procedure is a repeat, planned procedure. Often, only the procedure should be billed on that date.

If the procedure is a minor procedure, with global days of 0 or 10, use modifier 25 on the E/M service. If the service is a major procedure, with a 90 day global period, use modifier 57 if the visit was the visit at which the decision to perform the surgery was made.

When not to bill an E/M service and a procedure on the same day:
- When the patient is in the office for a procedure, and you stop by to say, “Hi”

- When you do not document the E/M service

- When the documentation is brief, and does not meet the components required
for history, exam and medical decision making

- When the service is not medically necessary

- When the procedure is a repeat, scheduled procedure and no new history or
medical decision making is needed or performed


Modifier -25 tells the payer that the E/M service was a significant, separate service from the procedure and was over and above what is typical pre and post procedure work. A separate diagnosis is not required. Do not routinely bill an E/M service with the procedure--make sure that it meets the requirements.

re: CPT® coding and surgical packes

When I receive the statement from Public Aid, under the E/M code it states " surgical package previously paid"

re: CPT® coding and surgical packes

Medicaid makes up its own coding rules. Because they are state programs, no two states process claims the same way. We wish they would follow CPT® rules, but they don't.