“Medicare pays approximately $40 more for an E/M 99213 versus an injection for a neuroma injection. Can you give the injection and only bill the E/M 99213?”
The rule of thumb for medical coding and billing is to bill for what you performed and documented in the medical record for the date of service in question. Even though an E/M service such as CPT 99213 reimburses at a higher amount than the procedure that was performed, a neuroma injection, as stated in the above post, it is highly inappropriate to bill for the E/M service as opposed to the CPT/procedure code that was performed. I am being kind by labeling the scenario as “highly inappropriate.” In reality, when a service is billed based upon the fact that it reimburses at a higher rate than the service that was actually performed, this should be labeled as fraudulent.
I believe that it is important to address specifically what IS an E/M service.
1. E/M is NOT a synonym for an office visit.
2. 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.
Take a good look at numbers 4, 5 and 6 above. This answers the posted question.
This is my opinion.
Michael G. Warshaw, DPM, CPC
GREAT NEWS!!!
THE 2024 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flashdrive formats. It has been completely updated for the calendar year 2024. 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, Florida 32757
Read Comments