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5846E&M Coding with Procedures

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  • Melinda
    Apr 19, 2013
      Does anyone know where this source might be from? A CMS MedLearn Matters
      (MM),
      or Change Request (CR)? Another local clinic is asking me if I might
      know about
      this. Does anyone know the details?

      The local clinic OM is being lead towards this:
      See 30.6.6 & 30.6.7 & Section 40 -
      http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/c\
      lm104c12\
      .pdf
      <http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/\
      clm104c12.pdf>

      The wording below is from the clinic home office. I'm trying to discover
      the
      validity vs hearsay. I did tell the local office OM that she really
      should try
      to find the CR or MM, if it exists.

      Thanks!
      Melinda Brown, CMBS
      Ins Biller

      "Medicare has issued a notice about a change in how providers must bill
      for
      procedures that are performed at the same visit as an E&M code. Medicare
      will
      no longer allow providers to bill for the E&M, whether for a new or
      established
      patient, when a procedure is performed that has a 0-10 day global period
      associated with it. If a provider does an evaluation that leads to a
      procedure
      at the same visit, only the procedure can be billed. If other problems
      are
      evaluated during the visit that are unrelated to the procedure, a
      modifier 24 is
      attached to the E&M for the unrelated problems and the E&M can be
      billed. This
      information comes from the National Correct Coding Initiative, and has
      been
      verified by our CHS coding experts. Our business office and coders have
      been
      educated on this change.

      Examples:
      1. A primary care provider evaluates a patient for a cough, documents an
      appropriate E&M service, prescribes medication, and gives instruction on
      home
      treatment. The patient also has a skin lesion that the provider wants to
      biopsy, and performs the biopsy during that visit. The provider can bill
      for
      the evaluation of the cough with a 24 modifier, and bill separately for
      the skin
      biopsy.

      2. An orthopedist sees a patient for a consultation about a painful knee
      and
      decides to inject the knee at that visit. The only problem the doctor
      addresses
      is the knee. Only the injection can be billed, not the office visit E&M.
      The
      payment for the injection covers the evaluation that resulted in the
      injection.

      3. An urgent care provider sees a patient for a head injury with a head
      laceration. The provider evaluates the head injury with appropriate E&M
      services, orders a CT scan of the head, and repairs the laceration. An
      E&M can
      be billed for the closed head injury with a 24 modifier, and the
      laceration
      repair can be billed as a procedure. But, if the only evaluation was for
      the
      laceration without doing an evaluation for the closed head injury, only
      the
      laceration repair would have been billed.

      This is only for Medicare so far. We think other payers will continue to
      pay
      for both the E&M and the procedure for the time being. We will have
      Athena and
      our coders be on the alert for this situation, and correct the billing
      for
      Medicare when necessary. Please contact your coder if you have
      additional
      questions about this change."




      [Non-text portions of this message have been removed]
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