Are you billing an E/M when you shouldn’t? Part II

Monday, April 24, 2023

In this issue of Coffee and Coding, we continue discussing when to bill an E/M and when you should not for the AWV (Annual Wellness Visit). NGS (National Government Services) has addressed when an E/M can be reported with an AWV on the Evaluation and Management, FAQs, IPPE, and AWV pages.

1. When a patient with several chronic conditions is scheduled for a follow-up visit, can the provider separately bill for an annual wellness visit performed on the same day?

Answer: Some chronic and stable conditions may not require assessment beyond the AWV, while others may require additional clinical examination and review or changes to the plan of care. This decision is within the realm of the performing provider’s clinical judgment. When additional history, examination, and MDM are indicated to fully assess a patient’s clinical status, a separate E/M service may be performed and billed. Documentation of the E/M visit should clearly support the medical necessity of the separate service.

2. When is an E/M service separately payable on the same DOS as the AWV?

Answer: The AWV has been designed as an annual overview of the patient’s health status, including physical and mental health elements and general safety. It may be performed by clinical staff under physician or NPP supervision and includes a review of known chronic conditions.

In some situations, the patient’s chronic (or acute) condition(s) may require evaluation and management by the primary healthcare provider (physician or NPP). Documentation for these services may be included in one note or in two separate notes, based on the provider’s preference. Of note, the documentation must clearly delineate all necessary details of the AWV and all the required elements of the E/M service relative to medical necessity and level of coding.

Next time you consider adding an E/M to a scheduled injection, scheduled lab work, or planned procedure, you should assess whether the E/M is separate, unrelated, above and beyond the typical work for the service, and medically necessary—the exact needs to be considered when adding an E/M to a yearly physical or Medicare AWV.

Modifier 25 audits did not vanish with the updated E/M guidelines. In fact, they appear to be on the rise. We recommend assessing your use of Modifier 25 and performing a self-audit. Please reach out; we will be happy to address your questions.

Retrieved 3/27/2023 https://www.cms.gov/medicare-medicaid-coordination/national-correct-coding-initiative-ncci/ncci-medicare

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