PRV1_0119_ProviderManual-Commercial.pdf

According to the american medical association em

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According to the American Medical Association, E&M services may be reported separately if, and only if, the patient’s condition requires significant, separately identifiable E&M service, which may be in connection to a new patient or a second diagnosis. However, the presence of a second diagnosis does not necessarily qualify an E&M service as “separately identifiable”. PacificSource policy for considering a second diagnosis will be as follows: If a second diagnosis represents a new condition, and requires significant evaluation and management of a separate body system, an E&M code may be reported. Modifier -25 must be attached to the E&M code. PacificSource reserves the right to determine, by chart note evaluation, whether or not an E&M service is warranted. If a second diagnosis represents a brief recheck of an ongoing, but unrelated condition, an E&M service will be processed to provider write-off. If a second diagnosis represents the same body system and/or condition, an E&M service will be processed to provider write-off. Modifier -25—Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service. The physician may need to indicate that on the day he or she performed a CPT code-identified procedure, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided.
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Section 11 | Billing Requirements 62 11.2 Global Period “Global period” is defined as the period of time when services must be included in the surgical allowance. PacificSource uses the number of days indicated in the “Global Period” column of the Federal Register as the standard. PacificSource considers the following services to be included in the global surgical package. These services are not separately reimbursable when billed by the same physician or by another physician within the same Provider Group (same Tax ID number). Services include: • Preoperative E&M services after the decision to perform surgery is made, one day prior to major surgery, and on the same day a major or minor surgery is performed; • Intraoperative services that are a usual and necessary part of the surgical procedure; • Anesthesia provided by the surgeon (including local infiltration, digital block or topical anesthesia); • Supplies; • Normal, uncomplicated follow-up care for the period indicated in the Federal Register Global Period; and • All additional medical or surgical post-operative services required of the surgeon during the post- operative period due to complications that do not require additional trips to the operating room. PacificSource considers the following services to be not included in the global surgical package: • Preoperative services not encompassed in the global period; • Evaluation and management services unrelated to the primary procedure; Services required to stabilize the patient for the primary procedure; • Procedures required during the immediate
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  • Winter '16
  • Dr. Vincent Onyebuchi
  • PacificSource

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