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New Medicare guidelines for consults

Discussion in 'Pain Medicine' started by member, Jun 23, 2006.

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  1. member

    member Junior Member 10+ Year Member

    Aug 9, 2005
    Can anyone eloborate on the new guidelines for consults. If an ortho or Int Med doc refers me a pt with LBP for management and I perform ESI and ask him to f/u in 1 week:
    IS this a consult for initial procedure and then f/u visit for billing purpose


    Is it a new pt visit for the procedure and then f/u visit

    WHY? :rolleyes:
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  3. algosdoc

    algosdoc algosdoc 10+ Year Member

    May 3, 2005
    Consultations or new patient self referred visits with same day procedures fall under the CMS Correct Coding Initiative that states:

    " Modifier -25: Modifier –25 is identified in the CPT Manual as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. This modifier may be appended to an evaluation and management (E & M) code reported with another procedure on the same day of service. The NCCI includes edits bundling E & M codes into various procedures not covered by global surgery rules. If in addition to the procedure the physician performs a significant and separately identifiable
    E & M service beyond the usual pre-procedure, intra-procedure, and post-procedure physician work, the E & M may be reported with modifier –25 appended. The E & M and procedure(s) may be related to the same or different diagnoses." taken verbatim from CHAP 1.doc Version 11.3

    Therefore, if one sees a patient referred for consultation, and then an injection is performed the same day, the 25 modifier is applied to the E&M Code Medicare holds that supporting documentation for the E&M Code must be available in the chart when used with a 25 modifier.
    Medicare holds that the procedure must be separately identifiable as a needed service...for instance, a follow up patient returns being treated for knee pain. The physician performs an injection of the knee on that visit, but cannot bill for an E&M Code the same day unless the code supports a separate problem.
    In general, it is better to avoid doing the procedure on the same day as n initial visit since the 25 modifier use and abuse of this code is being tracked by medicare carriers....
    It is legal to perform an injection the same day on the patient sent for consultation but not apparently for an injection alone... Confusing? You betcha!
  4. member

    member Junior Member 10+ Year Member

    Aug 9, 2005

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