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Billing for a same-day service and minor procedure

From the October ACP-ASIM Observer, copyright 2001 by the American College of Physicians-American Society of Internal Medicine.

By Brett Baker

Q: Will Medicare pay for an initial (or subsequent) hospital visit and a minor procedure provided on the same date?

A: Medicare typically does not pay for an evaluation and management (E/M) service provided on the same date as a minor procedure. It considers the E/M service a routine preoperative visit that cannot be billed in addition to the procedure, even if the E/M service resulted in the decision to perform the procedure. The Centers for Medicare and Medicaid Services (CMS), formerly HCFA, defines "minor procedure" as a service with a zero- or 10-day global (postoperative) period. The services included in the zero-day minor procedure global period are: preoperative visits related to the surgery on the date of the surgery; the procedure itself; complications resulting from the procedure; and postoperative visits pertaining to the procedure.

Therefore, Medicare will not reimburse you for an initial hospital service, such as CPT 99223, that prompted you to perform a procedure such as a lumbar puncture (CPT 62270), because Medicare assigns the procedure a zero-day global period. It will only pay for the lumbar puncture if you billed CPT 99223 and 62270 for the same patient on the same date.

However, Medicare will reimburse you separately for providing an E/M service on the same date as a minor procedure if the E/M service is significantly beyond the scope of preoperative services normally associated with the procedure. This means that the E/M service could be unrelated to the procedure or pertain to service provided above and beyond what is typically furnished on the same date as the procedure. You should bill a separately identifiable E/M service on the same date as a procedure by appending CPT modifier -25 to the E/M service. See the description of modifier -25 in CPT 2001 for more information.

Medicare recognizes modifier -57 (decision for surgery) only when it is appended to a procedure code that is assigned a 90-day global period ("major surgery"). E/M services provided the day before or the day of major surgery that result in the initial decision to perform surgery are not included in the global payment and can be billed and paid separately. See the description of modifier -57 in the CPT 2001 for more information.

Q: Why does Medicare pay for the procedure instead of the initial hospital visit, which has a higher reimbursement rate?

A: CMS considers payment for an E/M service furnished on the same date as a procedure with a zero- or 10-day global period to be routine preoperative care. Medicare reimbursement for a procedure with a zero- or 10-day global period will often be higher than the rate for an E/M service provided on the same date. However, this is not always the case. For example, Medicare pays $160.69 for a high-level initial inpatient hospital visit, CPT 99223, compared to $66.19 for a lumbar puncture in the facility setting.

Q: Can physicians bill Medicare only for the hospital visit and simply not report the procedure?

A: CMS states that it cannot prevent a physician from billing for an E/M service in lieu of a minor procedure when both are performed on the same date. If you choose to report only the E/M service, you must still document the minor procedure in the patient's medical record.

Below is a list of the payment rates for hospital visits and consultations. Compare the applicable E/M service rate to the reimbursement for the minor procedure to determine how to bill to optimize your reimbursement. Payment rates vary geographically.

CPT Code 2001 Payment Rate

Initial Hospital Care

99221 $71.55
99222 $117.46
99223 $160.69

Subsequent Hospital Care

99231 $35.96
99232 $57.39
99233 $81.49

Initial Inpatient Consultations

99251 $42.47
99252 $77.67
99253 $104.83
99254 $148.49
99255 $203.16

Brett Baker is a third-party payment specialist in the College's Washington office. If you have questions about third-party payment or coding issues, contact him at 202-261-4533 or bbaker@acponline.org.

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