tci Medicare Compliance & Reimbursement - 2016 Issue 7
Reader Question: Use 25 with New Prolonged Services Codes to Max Out Payment
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Article Overview
This article addresses a coding question involving a new patient office visit, a colonoscopy, and additional counseling time provided by a non-physician in a gastroenterology setting. It discusses how the encounter is framed for reporting purposes, highlights the related CPT code set and modifier use, and notes uncertainty about payer payment for the newer prolonged service codes. The piece is aimed at coders and billing staff who need to evaluate whether the scenario fits current CPT guidance and payer policy.
Why This Topic Matters
It helps coding and billing professionals understand how multiple services and added time may be represented on the claim, and why payer policy review remains important when newer CPT items are involved.
What You Will Learn
- How a gastroenterology encounter with both an E/M visit and a procedure is discussed from a coding perspective.
- How additional counseling time by clinical staff is treated in the context of prolonged service reporting.
- Why payer acceptance can be a separate issue from the existence of a CPT code.
- How modifier use affects reporting of same-day services in this scenario.
Who Should Read This
- Medical coders
- Billing specialists
- Revenue cycle staff
- Gastroenterology practice staff
- Compliance teams
Codes Discussed
Modifiers Discussed
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