CPT Reporting an E/M in lieu of minor procedure

[Stephanie7480]

I am looking for guidance please.
Is it the discretion of the provider to report an E/M in lieu of minor procedure. I need something official-like to serve as a solid reference either way.
I am bombarded with information about reporting minor procedure with an e/m when I try to search "in lieu of" but that is not what I need.
If anyone can assist I would greatly appreciate it.

I did find this but am unable to locate the said refrence from CMS
http://www.acpinternist.org/archives/2001/10/billing.htm

Thanks!

 

[louise]

Hi Stephanie,
Thanks for posting this very interesting question!

To quote near the bottom of your reference:
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. (underline is mine)

This answer doesn't exactly match your question though. You are wanting to REPLACE a procedure code with an E/M code. This answer addresses the situation when BOTH the procedure and the E/M are performed.

I looked to see if I could find that statement by CMS, without success. The fact that it's not readily addressed seems worrisome to me and would mean I should inquire further. I found myself returning to the AHIMA codes of ethics for coders and for CDI professionals.

There are some basic tenets that must be upheld. You must use a code that represents work done and there must be documentation of medical necessity. So with those being true, yes, I guess one might consider an E/M in lieu of a procedure code if 1) the use of the E/M code is not to circumvent a particular plan's denial of coverage, 2) and/or the procedure/service isn't included the global period of another procedure/service. But this still doesn't sit with me since CPT guides us to use Cat III or unlisted codes when no exact code matches the work done.

I think I've just stirred up the mud a bit more....