What does the decision to perform a minor procedure really mean?

I received this question recently and want to share it with you.

“Since the decision to perform a minor procedure is included in the payment for the minor procedure, does this mean we can never bill an E/M and a procedure on the same day for the same condition?”

It doesn’t mean you can never bill an E/M and a minor procedure on the same day.  You can bill an E/M and a minor procedure (procedure with 0 or 10 global days) on the same calendar date.

The writer quoted the CMS Claims Processing Manual. The same language is in the CMS manual and the NCCI manual.  I’m sure you’ve read it.

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 should 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.

The first and second sentences would lead you to believe you can’t.  Then, the third and fourth sentences would lead you to believe you can.  Both CPT^® and CMS say that a different diagnosis is not required.

• The procedure code includes typical pre and post work, not a significant and separate evaluation of a condition.
• The NCCI manual does give one clinical example.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.
• Pre-work is site assessment, decision to perform the procedure, informed consent, obtaining information about allergies, obtaining information about immunization status, if relevant.
• Post-work includes post procedural instructions.
• When a physician/NP/PA needs to evaluate a condition and consider treatment options prior to the decision for surgery, bill for both.

In the latest edition of the AMA’s Principles of CPT^® Coding 9^th ed, there is a decision tree regarding using modifier 25. The first question in the tree is “Does the documentation support that’s the patient’s condition required a separate and distinct E/M service, above and beyond the usual preoperative and postoperative services for the procedure?” And, keep in mind that contrary to some payer edits, both CMS and CPT say that the same diagnosis may be used to report the E/M service and the procedure.

When reviewing a note, assess whether the documentation shows work that is in addition to the typical pre and post work of the procedure.

Procedures do have pre and post work valued into the procedure.

You can download the NCCI manual yourself.