q & a
Same-day Exams & Minor Surgery
Medicare's rule allows exceptions.
By Suzanne Corcoran, C.O.E.
Exams performed on the same day as minor surgery procedures are usually considered incidental and aren't paid separately. Medicare does permit some exceptions, which I'll explain.
What's a minor surgical procedure?
Answer: Medicare defines minor surgical procedures as those with zero or 10-day postoperative periods, such as foreign body removal (65222), punctal occlusion with plugs (68761) and epilation for correction of trichiasis (67820).
When may I bill Medicare for an exam on the same day as a minor procedure?
Answer: You may bill for an exam or consultation on the same day as a minor procedure when the patient's condition requires an additional service beyond the usual care provided as part of a procedure.
Use modifier 25 with the exam (992xx or 920xx) or consultation code (9924x) to indicate that you've performed a separately identifiable service on the same day as a minor procedure. Modifier 25 is defined by CPT as a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service." If the only purpose of the exam is for preoperative care, then a claim for an office visit with modifier 25 is not appropriate.
If you're seeing a patient for more than one problem (e.g., a regularly scheduled glaucoma follow up and to address complaints of foreign body sensation), then it's appropriate to bill for the exam and for removing the foreign body.
Do I need different diagnoses for the exam and for the minor procedure?
|When Not to Bill
An established patient presents with continued complaints of dry eyes. She has a history of dry eye and has tried a variety of drops without success. When you last saw her, you both agreed that you'd try occluding the
puncta. Today, you insert punctum plugs in the two lower
puncta. Because you planned the occlusion in advance, today's visit is just for the minor procedure -- you don't charge for an exam.
Answer: No. The CPT definition of modifier 25 states that, "The evaluation/management (E/M) service may be prompted by the symptom or condition for which the procedure and/or service was provided . . . different diagnoses aren't required for reporting of the E/M services on the same date."
Will billing for both an exam and a minor procedure increase my risk of being audited?
Excessive use of modifier 25 will garner undesirable attention. Thorough documentation of the medical necessity for the visit as a separately identifiable service is the best defense against postpayment recriminations.
As always, documentation is critical. The exam and minor surgery may appear on the same page in the medical record, but we don't recommend you leave it that way.
I suggest that you use a separate operative report for the surgery. This report should contain the indications for the procedure, a thorough description of the procedure and your discharge instructions.
You should also include documentation clearly indicating that the patient gave you his consent. You can download a Minor Procedure Consent and Treatment form at no cost from our Web site
Suzanne Corcoran is vice president of Corcoran
Consulting Group. Reach her at (800) 399-6565 or at SCORCORAN@CORCORANCCG.COM.
Optometric Management, Issue: February 2003