Coding and Billing

When You Can—and Cannot—Charge an Exam Fee

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD

Sept. 5, 2018

“Can you charge an E/M service on the same day as a minor surgical procedure?”

The answer is both yes and no. Let’s explore this question and find out when the answer is yes and when the answer is no.

A minor surgical procedure is any surgical procedure with a zero-day or 10-day global period, and a major surgical procedure has a global period of 90 days. A few examples of minor surgical procedures would be:

• Punctal Occlusion By Punctal Plug, CPT 68761
• Corneal Foreign Body Removal with Slit Lamp, CPT 65222
• Correction of trichiasis; epilation, by forceps, CPT 67820
• Yag Laser Capsulotomy, CPT 66821
• Trabeculoplasty by laser surgery, CPT 65855

What are the billing rules? The Medicare rule states, “The initial evaluation for minor surgical procedures … is always included in the global surgery package” , and the National Correct Coding Initiative (NCCI) edits routinely bundle E/M services with minor surgical procedures. So, it would seem that the answer is that you cannot charge and be paid for an E/M service when you also charge for a minor surgical procedure.

But, an exception to the rules exists, so the answer may be yes. The exception to the rules stated above is if the E/M service is for a different complaint or for a different concern, then the E/M service may be reported separately.

EXAMPLES
Three examples of when you can and cannot bill an E/M code, in addition to a minor surgical procedure, will be helpful here.

Example 1
When a patient comes into the office and you discover a corneal foreign body and immediately order a corneal foreign body removal, and that is the only problem you are dealing with, then you can only charge for the corneal foreign body removal. You cannot also charge an E/M visit plus the corneal foreign body removal.

Example 2
A patient presents to the office for punctal plugs to be placed in the right eye. When the patient arrives, she has a scratched left eye that occurred when playing with her infant last night. The left eye is a different complaint, which needs to be evaluated and treated in addition to the scheduled minor surgical procedure for the right eye. In this situation, it’s appropriate to bill the E/M service code with modifier -25, in addition to the punctal plug insertion procedure.

Example 3
A patient presents to the office for correction of trichiasis; epilation, by forceps for his left eye. During the visit, he mentions that he has been having flashes and floaters in his left eye after a fall yesterday. It’s appropriate to bill an E/M code with modifier -25 to evaluate the left eye for the flashes and floaters in addition to the minor surgical procedure on the left eye.

NOTES
Note 1: To bill for an E/M service on the same day as a minor surgical procedure, use the appropriate E/M code with modifier -25. (CPT defines modifier -25 as significant, separately identifiable evaluation and management service by the same physician or other qualified health-care professional on the same day of the procedure or other service.)

Note 2: The Office of Inspector General has taken an interest in the improper use of modifier -25, so only use this modifier when appropriate. Use it, don’t abuse it.

Note 3: The significant, separately identifiable problem can be either on the same eye or a different eye as the minor surgical procedure.

BEST PRACTICES
If you are going to bill an E/M code, in addition to a minor surgical procedure, there are two best practices you should utilize:

1) A best practice is to separate the E/M documentation from the minor surgical procedure documentation.

2) A best practice is to use this outline for your minor surgical procedure documentation:

• Medical condition
• Previous Tx
• Informed consent
• Procedure
• Outcome statement
• Discharge instructions

References
i. Medicare Claims Processing Manual, Chapter 12, Section 40.1.B
ii. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

 

These articles may also interest you:

How Much is Faulty Coding Costing You?

New Coding & Billing Rules for 2018

Medicare Physician Fee Schedule Lookup: Know the Codes to Make Revenues Flow

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