It may be necessary to indicate that on the same day as a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.
A typical scenario is when a patient has an appointment for a routine physical exam and at some point, the patient mentions a health issue they are experiencing. Historically, BCBSM/BCN would not reimburse both services when performed on the same date of service by the same physician or other health care professional. Because there is a new complaint, a separate exam and time are spent on the new complaint, which requires additional medical decision making. Therefore, a separate service can now be billed and reimbursed at 50% of the physician fee schedule.
With the revision in policy, patients will now, potentially, have a copay assessed for the problem-focused E/M service. Patients do not have copays for routine physical exams, so it is important to educate patients that a copay assessed for the issue, unrelated to the routine physical exam, may be required.
