Reporting an Office Visit and a Surgical Procedure during the same encounter

As you may know, there has been a recent rash of Medicare audits requesting provider treatment notes. These notes are subsequently matched up against claim information to make sure that claims were reported and paid correctly. With this in mind, I want to clarify the procedures currently in place that govern preparation of your claims by my staff:

If you report an Office Visit (992xx) AND a Surgical Procedure on the same day, a “-25” modifier is included with the OV code to distinguish its “unrelated” status.

  • When separate Dx codes are reported for the OV and the procedure, this is clearly the correct way to prepare the claim.
  • When only one Dx is reported, use of the “-25” modifier indicates that the same condition existed at more than one site. In other words, these multiple appearances of the same condition were treated in an “unrelated” fashion by an OV (evaluation/management procedure) AND a surgical procedure. If challenged, your notes must support this scenario
  • If an OV and a procedure are reported for the same condition/same sight, the “-25” modifier is inappropriate and must not be included. NOTE: There is no way for me to tell if this is the case; as both codes are rarely paid in this scenario, I recommend reporting the one with the higher value by itself..

Some insurance companies will support payment of consultations and new patient office visits even if a procedure is performed during the same encounter. Few insurance companies allow payment of office visits on established patients when a procedure is performed in the same session, however, some do and you are entitled to that fee.

The point of this memorandum is to stress accuracy. I want you to understand how your claims are being coded and to concur with the current procedures. If you have any questions, please call at your convenience. Together, we can achieve accurate claims and timely, correct payments.

Current Strategies 2010

I want to take this opportunity to point out some recent improvements and others that will be completed in 2010. It is important for you to know that the right things are happening to ensure consistent results with your billing services.

  • Follow Up
  • Delinquent claims can account for as much as 20% of your potential payments. Online accounts were established with insurance companies wherever possible so that claim status and coverage information can be determined more efficiently. Also, we are tracking claims based on “risk of denial” rather than “age of the claim” in order to engage discrepancies in time to avoid denials. These enhancements will result in faster payments and reduced denials.

    My goal in 2010 is to close all claims in 90 days or less AND to eliminate all denials for timely filing.


  • Software Upgrades
  • In January, I installed LYTEC 2010 practice management software on my system. This software is fully HIPAA compliant and offers a number of features not available in previous versions. Remote access to reports, schedulers, and patient files are some of the attractive features. I will be working with the vendor to offer new services to clients who express interest.


  • New Server & Internet Connection

As the role of the Internet grows in successful billing operations, the demand for more powerful computers and high speed connectivity grows as well. Our internet connection uses business class fiber optic technology. All computers on our network have been upgraded to Pentium 4 technology with increased memory and the Windows XP Professional operating system. I have purchased a new Dell quad-processor server to enhance the performance of the new LYTEC software. The terminal server which manages traffic from remote locations has been upgraded to the Windows 2003 Server operating system. Wiring and switching throughout the office is all CAT-6 further guaranteeing the best performance available.


I hope you see the value of these improvements. They all focus on better results in collecting your fees and a strong position for your future needs. I want you to know that I am taking the necessary steps to provide the best billing services available at competitive prices.