For Oxford and Health First, do I bill initial visit? Or do I bill the procedure codes? Both will not work.
The answer to this does not differ based on the payer. For all payers:
Now, some definitions and references to support all that:
Almost every service provided is either a procedure or an E&M. The documentation for the service must differentiate between the two. A procedure occurs when something is done to a patient, physically. Examples of procedures include cutting, debriding, injecting, and performing an operation. An E&M occurs when a complaint is evaluated by way of history and exam and the patient’s condition is medically managed. Examples of the management component of an E&M include writing a prescription, making a recommendation, suggesting an over-the-counter product, and referring a patient to another provider. An "H&P" is not the same as an "E&M." Rather, an "H&P" may represent the "E" portion of an E&M.
With some exception, both an E&M and a procedure cannot be submitted for the same patient during the same encounter. Chapter I, Section D of the National Correct Coding Initiative Policy Manual For Medicare Services1 states, “An E&M service is separately reportable on the same date of service as a procedure under limited circumstances.” That limited circumstance is when the E&M is significant and separately identifiable from the procedure. An E&M is significant and separately identifiable from a procedure if there is no overlap in the work associated with the provision of the E&M and the work associated with the performing the procedure. Chapter I, Section D of the National Correct Coding Initiative Policy Manual For Medicare Services states a significant and separately identifiable E&M exists if it does not “include any work inherent in the procedure, supervision of others performing the procedure, or time for interpreting the result of the procedure.” There cannot be any overlap in the work associated with the E&M and the work associated with the procedure, and that must be supported in the documentation. “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure, and shall not be reported separately as an E&M service.”
The CPT book reinforces much of this by stating an E&M may not be considered “significant and separately identifiable” from a procedure if that E/M “resulted in a decision to perform” the procedure.
This guidance applies to both new and established patients. The National Correct Coding Initiative Policy Manual For Medicare Services makes this clear in Chapter I, Section D by stating, “The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”
When a significant and separately identifiable E&M and a procedure are both performed, it is essential that the documentation clearly reflect two separate services with no overlap in work between the E&M and the procedure.
In your submission you wrote, "Both will not work." A payer not paying for both does not necessarily mean it was coded incorrectly. If both an E&M and a procedure that IS significant in nature and separately identifiable from the procedure are both performed, and the documentation supports this, then both the E&M and the procedure should be submitted and recognized by the payer. If all of these guidelines are followed and you are experiencing inappropriate denials, I suggest coordinating with your administrative defense coverage carrier to contest these inapproproate denials.
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2023 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC