Why can’t an E/M service be billed every time that a procedure is performed on a patient in the office setting?
When can an E/M service be billed when a procedure is performed on a patient in the office setting?
- E/M is NOT a synonym for an office visit.
- It is a 2 part process:
a. “E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS. This shows MEDICAL NECESSITY.
b. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.
- • And, if that is not enough,
4. ALL CPT (Procedure) codes have an inherent E/M component.
5. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and separately identifiable.
6. You can NEVER, EVER bill an E/M code in lieu of the appropriate CPT code.
Appropriate Uses of the 25 Modifier
- • The 25 modifier is used to demonstrate that a SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE was performed on the SAME day of a MINOR surgical procedure by the SAME physician.
The 25 modifier is only used on an E/M service.
- • An INITIAL E/M service CAN be billed when performed on the SAME date of service as a minor surgical procedure code.
The diagnosis code for the INITIAL E/M service and the diagnosis code for the minor surgical procedure CAN be the SAME.
- • AN ESTABLISHED patient E/M code CAN be billed when performed on the same date of service as a minor surgical procedure code.
The diagnosis code for the established E/M service MUST BE DIFFERENT from the diagnosis code for the minor surgical procedure.
There can be absolutely, positively NO CORRELATION between the E/M service and the minor surgical procedure.
- • If an established patient is seen for a NEW problem that has never been evaluated for previously (ie. never mentioned, never examined, never treated) and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service and the diagnosis code for the minor surgical procedure can be the SAME.
Of course, the entire scenario needs to be completely documented in the medical record.
This is my opinion.
Michael G. Warshaw
THE 2022 Podiatry Coding Manual is now available in either Book or Flashdrive formats. It has been completely updated including the E/M coding changes. Many offices across the country consider this to be their “Bible” when it comes to coding, billing and documentation. The price is still only $125 including shipping! To purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for $125 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, FL 32757
Are you in compliance with Medicare concerning your billing, coding and documentation? An audit should never be more than an inconvenience. It should not be a life altering event. Find out your status before you are audited by your Medicare carrier. Drmikethecoder special: Have 5 dates of service audited for $250 (new clients only). Contact drmikethecoder.com for more information.