Rachel Rogers asked:
I have just started Pro Fee coding at the top hospital in my region four months ago. My research has provided me with some information but I still have additional questions that my department educator has given me two opposite answers on leaving me confused.
From my understanding; when a patient is coming in for a complaint (shoulder pain; etc) HPI; ROS; Exam; is all completed; and the provider decides to do a joint injection procedure the E/M level is coded based on documentation of the note with modifier 25 and the correct CPT is assigned to the procedure. The same Diagnosis codes are appended to both the E/M and procedure code (shoulder pain).
My question is; what elements of an E/M are included in a 10 day global procedure? Are they the vitals; updating medication list; and/or current state of complaint; etc? Or is an HPI; ROS; exam ; and MDM included in a 10 day global procedure? If only the vitals; medication list and current state of dx are the only elements included in the procedure then how is a note coded when a patient comes in for only a procedure (wart removal etc) and the provider documents all the elements of an E/M but nothing to indicate that he/she went above and beyond? For example; the patient came in for wart removal and there is a Detailed History; Detailed Exam; and Low MDM along with the procedure documented in the note. The diagnosis is Viral Wart. Is only the procedure coded even though it includes all HPI; ROS; exam and MDM?
Also; I am being told by my educator that when a provider goes above and beyond I am only allowed to use the elements that do not pertain to the body system the procedure was done on. For example; the patient had an endometrial biopsy done and the provider is also addressing hypertension;therefore; when I level for an E/M I have to exclude the body system the procedure was done on (GU). My educator originally told me a few days prior that I can ONLY use the body system that I am leveling on; meaning I"d only be able to use anything related to Hypertension in the Cardiovascular system.
If you could please so help me or direct me to where I can find these answers through our credible sources I would be so forever grateful. Thank you.
Answer:
These are really good questions. I was able to find a few references for you regarding your questions. Here are the links:
Know When to Bill E/M with a Minor Procedure <https://www.aapc.com/blog/27690-know-when-to-bill-em-with-a-minor-procedure/>
This is stated in the above link for know when to bill E/M with a minor procedure "Per CMS rules; every procedure (whether major or minor) includes an "inherent" E/M component and; as such; you generally may not report a separate E/M service on the same date of service. This rule is repeated throughout CMS policy documents; but is succinctly explained in the Medicare Claims Processing Manual; Chapter 12; Section 40.1.C:" Here is the link to the Medicare Claims Processing Manual <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf>
Your Quick Guide to the Global Surgical Package <https://www.aapc.com/blog/46373-your-quick-guide-to-the-global-surgical-package/>
I have just started Pro Fee coding at the top hospital in my region four months ago. My research has provided me with some information but I still have additional questions that my department educator has given me two opposite answers on leaving me confused.
From my understanding; when a patient is coming in for a complaint (shoulder pain; etc) HPI; ROS; Exam; is all completed; and the provider decides to do a joint injection procedure the E/M level is coded based on documentation of the note with modifier 25 and the correct CPT is assigned to the procedure. The same Diagnosis codes are appended to both the E/M and procedure code (shoulder pain).
My question is; what elements of an E/M are included in a 10 day global procedure? Are they the vitals; updating medication list; and/or current state of complaint; etc? Or is an HPI; ROS; exam ; and MDM included in a 10 day global procedure? If only the vitals; medication list and current state of dx are the only elements included in the procedure then how is a note coded when a patient comes in for only a procedure (wart removal etc) and the provider documents all the elements of an E/M but nothing to indicate that he/she went above and beyond? For example; the patient came in for wart removal and there is a Detailed History; Detailed Exam; and Low MDM along with the procedure documented in the note. The diagnosis is Viral Wart. Is only the procedure coded even though it includes all HPI; ROS; exam and MDM?
Also; I am being told by my educator that when a provider goes above and beyond I am only allowed to use the elements that do not pertain to the body system the procedure was done on. For example; the patient had an endometrial biopsy done and the provider is also addressing hypertension;therefore; when I level for an E/M I have to exclude the body system the procedure was done on (GU). My educator originally told me a few days prior that I can ONLY use the body system that I am leveling on; meaning I"d only be able to use anything related to Hypertension in the Cardiovascular system.
If you could please so help me or direct me to where I can find these answers through our credible sources I would be so forever grateful. Thank you.
Answer:
These are really good questions. I was able to find a few references for you regarding your questions. Here are the links:
Know When to Bill E/M with a Minor Procedure <https://www.aapc.com/blog/27690-know-when-to-bill-em-with-a-minor-procedure/>
This is stated in the above link for know when to bill E/M with a minor procedure "Per CMS rules; every procedure (whether major or minor) includes an "inherent" E/M component and; as such; you generally may not report a separate E/M service on the same date of service. This rule is repeated throughout CMS policy documents; but is succinctly explained in the Medicare Claims Processing Manual; Chapter 12; Section 40.1.C:" Here is the link to the Medicare Claims Processing Manual <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf>
Your Quick Guide to the Global Surgical Package <https://www.aapc.com/blog/46373-your-quick-guide-to-the-global-surgical-package/>
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