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Posted By Mary Peabody on 04-15-2020, 14:15:38 in Ob-Gyn
Hello Melanie,

When billing Medicare for an E/M with a minor procedure on the same and the decision for the minor procedure was made at that visit (example patient seen for post menopausal bleeding and the provider decides to perform an endometrial biopsy on the same day, can you bill the E/M with modifier 25 and endometrial biopsy (58100)? The provider documents a detail HPI, detail ROS and performs a detail examination and documents in the assessment, the decision to perform the endometrial biopsy.
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Posted By Melanie Witt on 04-16-2020, 18:08:12
According to the CCI manual, the decision to do a minor procedure is included and so should not be billed separately. They emphasize that if you do bill an E/M it must be separate and significant. Lately I have been hearing the Medicare is automatically denying a same day E/M service and then asking the provider to prove it was separate and significant. The manual states the following:

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
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