T pellets: What are you allowed to charge?
Services beyond implantation must be ‘separately identifiable,’ ‘significant’ to justify modifier
I’m a urologist in a large multispecialty group that specializes in men’s health. I see a lot of men with hypogonadism and have a large number on implantable pellets. I recently received a letter from an insurance company requesting that I repay all the money I received for evaluation and management visits on the same day as the implant. Are they correct? Is it against the payment rules for me to evaluate the patient on the same day as the implantation?
No, it is not against the rules, in some scenarios. However, it would be against the rules in other scenarios. So, our answer would be “maybe,” or “depends.” We will try to delineate the rules and empower you to make an accurate decision as to whether to charge or not charge for each encounter.
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We will start with an assumption that your documentation qualifies for charging an E&M code with adequate documentation of the components or the amount of time spent during an encounter in which over 50% of the time was spent counseling or coordinating care.
The next question is, does the documentation show that the visit was medically necessary? In other words, was the service needed for good patient care? Then, last but not least, the documentation must justify the use of the –25 modifier. That means that this service has to be “separately identifiable” from the procedure; in this case, the implantation of the pellets. In other words, the service has to be more than getting the patient ready for the procedure, inquiring about their health and well-being, and determining whether the procedure should be performed on that patient that day.
You’ve already been paid for the preoperative preparation of the patient when you’re paid for the procedure. However, if you are evaluating the primary disease process and determining appropriate treatment and outlining additional diagnostic studies that are needed, you’re performing functions that are separately identifiable. In addition, we’ll restate the obvious: If you evaluate and/or treat another disease process in addition to hypogonadism, that service is “separately identifiable.”