09/06/2025    Richard Silverstein, DPM

Call To Action For Anyone Who Bills Office Visits

Recently, CMS release the 2025 NCCI Policy Manual,
which includes clarifications on billing
Evaluation and Management (E/M) services with
procedures.

https://www.cms.gov/files/document/2025nccimedicar
epolicymanualcompletepdf.pdf
Please see Chapter 1, pages 28-29.

Here is what CMS has said:

Here’s what CMS emphasizes:

Minor procedures (000 or 010 global days):

The decision to perform the procedure is included
in the procedure’s payment.

An E/M service on the same day is not
automatically billable, even for new patients.

To bill both, the E/M must be significant and
separately identifiable beyond the decision for
the procedure, with modifier 25 appended.

New patients:

Being new to the practice does not by itself
justify billing an E/M in addition to the
procedure. Documentation must clearly show that a
separately identifiable service was provided.

Major procedures (090 days):

If the E/M service is the visit where the decision
for surgery is made, it may be billed separately
with modifier -57.

* This means that if a NEW patient comes in and a
procedure is performed with a global of 0-10 days
you cannot bill the new office visit unless the
patient has a significant, separately identifiable
evaluation and management of a DIFFERENT diagnosis
by the same physician on the same day as a
procedure or another services.

*Who in their right mind comes to the office and
decides to have a procedure done as a NEW patient,
which has a global period of 90 days, on that same
very day? Think about that for a second!It hasn’t
happened in my 25 years of clinical practice.

*They say the E & M is built into the pricing of
the procedure but we all know a lot of work and
necessary effort is expended on taking a history
and physical of our NEW patient to make sure their
health and safety are taken into account, when
performing any procedure. They are basically
saying the E and M component is no different if
they are NEW or ESTABLISHED because its all built
into the procedure. We know there is a lot more
effort when we see a NEW patient.

*Mr. Smith (not diabetic with regular Medicare)
who presents as a NEW patient with a painful
ingrown toe nail, that is not infected, but
requires doing a phenol and alcohol with no other
problems or diagnoses at the time of presentation.
You can only bill the 11750 according to these new
guidelines (on the day they present) despite
documenting a chief complaint, HPI, medication and
allergy list, review of systems, lower extremity
physical examination, assessment and plan.

*For those that say, it isn’t infected, simply
reschedule the patient for the procedure at a
future time where you can bill the procedure (and
bill the initial office visit when they first come
in), I have verified that insurance carriers have
recouped the E and M visit, in the rears, after
reimbursing for it because they linked it to the
procedure, that was eventually done a few weeks
later. It is time to stop trying to find the work
arounds and to address this issue straight on.

*This issue affects every clinician who bills
office visits.

*It is the same as the following situation:

With the advent of ICD-10 it became clear to
insurance companies that a patient (when billing
for orthotics) may have a right sided painful
bunion (M20.11) but are requiring a different
diagnosis for the contralateral orthotic (as L3000
x1 unit, LT, does not match up in their software
edit using M20.11). Instead of fighting back, we
have many times been instructed by carriers to
find a code that fits the other foot.

We are the physicians, we determine what is
clinically relevant to any particular patient. We
found the work around but I believe carriers could
understand that creating a limb length discrepancy
by only covering one orthotic is not in the
patients best interest. In the end, we are left
having to do additional documenting of findings
instead of fighting back.

*Whatever starts with Medicare eventually trickles
down to other carriers (Advantage plans and
commercial carriers). I have even seen recently
the institution of the “class findings parameter”
of rules used for foot care coverage with Medicare
adopted by a Managed Care Organization which is a
privately managed state Medicaid here in Maryland.

APMA should be linking up with AMA to put a stop
to all this nonsense.

Richard Silverstein, DPM, Havre de Grace, MD

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