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Plans for future care; discuss pathology/genetic testing results

Kathy Posted Wed 27th of January, 2016 15:48:54 PM

A patient is seen during the post operative period of a surgery for malignant neoplasm or other major complex surgery, and during this visit, the provider discusses the pathology, genetic testing, etc. and/or discusses plans for the patient to move forward with other treatments, such as future surgery, referrals to oncology, radiation oncology &/or additional testing, which becomes a lengthy visit. To be clear, the provider spends very little time discussing the surgery he just performed... The counseling involves lengthy discussions of FUTURE TREATMENT &/or TREATMENT OPTIONS. Please explain why payors are not paying these E&M visits & give details examples of how we can demonstrate this IS a billable service?

SuperCoder Answered Thu 28th of January, 2016 03:30:07 AM

Per above mentioned scenario Evaluation & Management visit is after operative surgery for Malignant Neoplasm or Other major complex surgery, as the physician discussed about Specimen Pathology, Genetic testing & further treatment plan, it directs that the purpose of visit was related to the surgery performed, major surgery have a global period of 90 days following surgery which includes all evaluation & management visits included in that global period, So E&M will not be reimbursed separately.
When E/M will be paid or reimbursed: If the reason of E&M visit is purely different or unrelated for which surgery is performed & modifier 24 is used with E&M Visit.
Modifier 24: Unrelated evaluation and management service by the same physician during a postoperative period.
Example: In below mentioned scenario Eval &Mgmt. visit will be reimbursed separately, but if reason of visit will be C41.3 with 99213 then the Eval. &Mgmt. visit 99213 will be denied.
Claim Type Date of Service Place of Service Px code Modifier Diagnosis Codes
Current Claim 01-25-2016 11 99213 24 I20.9
History Claim 01-02-2016 21 23200 C41.3

Kindly check your scenario for Diagnosis code & modifier appended.

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