Fine. So, what does all this have to do with our readers? Recently, the Centers for Medicare and Medicaid Services (CMS), through its Medicare Learning Network (MLN), decided to use the IVI procedure to make a larger point about general billing propriety. It is this larger point that has relevance to many of our clientele.
The Type of Period
The MLN article, released late last year, advises that Medicare considers IVI to be a minor surgical procedure. Why is that important? Well, Medicare generally includes payment for any evaluation and management (E/M) service, performed on the same date as a minor surgical procedure, within the payment for the procedure. That is, the E/M is not separately reimbursed. Medicare’s National Correct Coding Initiative (NCCI) Policy Manual, Chapter 1, section D, has the following information on E/M services performed on the same date as a minor surgical procedure:
- If a procedure has a global period of 000 or 010 days, it’s defined as a minor surgical procedure
- In general, we include E/M services performed on the same date of service as a minor surgical procedure in the payment for the procedure
- The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure; it should not be reported separately as an E/M service
So, for procedures with either no or 10 global days, any E/M service on the day of the procedure is typically bundled into the procedure’s payment. Of course, the operative word there is “typically.” We’ll explore that rabbit hole a bit more below.
The Type of Procedure
The MLN article chose to use an eye injection as their example of not billing a separate E/M, but the basis of this guidance applies to all such procedures, i.e., procedures with a low global period. That means that for any procedure with a 0 or 10-day global period, the same rule would apply. This is where the MLN article particularly applies to many of our readers. For example, a chronic pain physician would need to abide by this same rule when he/she administers any of the following injection procedures in the office/outpatient setting (the MLN heading includes reference to these particular places of service):
- Joint injections
- Trigger point injections
- Peripheral nerve blocks
- Epidural steroid injections
- Facet joint injections
- Sacroiliac (SI) joint injections
Again, you typically cannot bill an E/M on the same date of service with these procedures. Such billing combinations are routinely reviewed by payers.
The Type of Patient
Well, what if it’s a new patient? Can’t I bill both the procedure and the E/M under that circumstance? The MLN article addresses this question, as well, utilizing the following bullets:
- If you perform a minor surgical procedure on a new patient, the same rules for reporting E/M services apply
- The fact that the patient is new to the provider or supplier isn’t sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure.
There is a belief among some that it’s always okay to bill an E/M for a new patient visit, along with the procedure, because there is extra work involved with a new patient. However, this is not sufficient in the eyes of Medicare.
Exceptions to the Rule
So, is there ever a circumstance when you can bill a separate E/M service along with a minor procedure when both are performed on the same day? Yes, but such circumstances should be deemed as fairly rare and not routine. Here’s how the MLN article puts it:
If a patient’s condition requires a significant, separately identifiable E/M service, add modifier 25 to the appropriate level of E/M service. For example, examining both eyes at the time of an injection to 1 eye isn’t a separately identifiable service. When you’re performing a pre-op exam, evaluate the patient’s fellow eye, and if that exam reveals a new diagnosis requiring a new management plan for a separately identifiable reason, we may consider it a separately identifiable service. The Medicare NCCI Policy Manual, Chapter 1, section E(b) has information on what’s considered a significant and separately identifiable service performed on the same date as a minor surgical procedure:
- You may append modifier 25 to an E/M CPT code to indicate the E/M service is significant and separately identifiable from other services reported on the same date of service. The E/M service may be related to the same or different diagnosis as the other procedures.
- Since minor surgical procedures include pre-procedure, intra-procedure and post-procedure work inherent in the procedure, the provider or supplier shouldn’t report an E/M service for this work. Medicare global surgery rules prevent the reporting of a separate E/M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.
Accordingly, to support a separately reportable E/M service on the same date as a minor procedure, documentation must clearly demonstrate that the E/M was significant and separately identifiable, as well as above and beyond the work associated with the procedure itself. Examples may include:
- Evaluation of a new or worsening condition
- Assessment of a separate complaint
- Treatment plan or medication changes
- Diagnostic evaluation not inherent to the procedure
- Medical decision‑making that stands independently from choosing the injection
The takeaway is that (a) providers should not assume that E/M visits are automatically billable with procedures, such as pain injections—even when the patient is new to your practice—and (b) where you believe the E/M service goes beyond the pre-op work associated with the procedure, you should ensure your documentation demonstrates why it is separately billable.