How a Doctor's Office Should Bill for Minor Medical Procedures

Physicians provide medical services in their office locations. Generally a physician examines their patient and diagnoses the symptoms the patient is having at the time of the visit. In addition to providing an examination and a diagnosis, physicians perform minor procedures in their offices, based on current procedural guidelines, and are reimbursed for the procedures by health insurance carriers. In order to be paid successfully for such procedures, the physician needs to be aware of the billing requirements for these eligible procedures.

Things You'll Need

• Basic medical billing knowledge
• Medicare Physician Fee Schedule Data Base (MPFSDB)
• CPT procedure book
• Healthcare Common Procedural Coding Manual (HCPCS)
• ICD-9-CM Diagnosis Book
• Evaluation and Management Documentation Guidelines manual
• HCFA Form or other insurance claim form
• Patient medical chart

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Instructions

• 1

  Minor surgical procedures can sometimes be performed in a doctor's office.

  Identify the minor surgical procedure code in the CPT procedure book. Check the procedure code's global period in the MPFSDB. The global period is the length of time the physician can perform pre- and post-op services that are included in surgery payment. According to Medicare, the global period for minor surgeries is up to 10 days. For example, in a global period of 10 days, the provider can bill the health insurance carrier for services that may be the same or related to the original surgery diagnosis on the eleventh day after the surgery and be paid.

• 2

  Verify that the physician-provided diagnosis warrants medical necessity for surgery using the ICD-9-CM Diagnosis book.

• 3

  Identify if any other procedures were performed by the physician for the patient on the same day by reading over the medical notes in the patient's medical chart. If the physician saw the patient for an office visit on the same day as well, verify that the surgery can be billed with an office visit using Medicare Physician Fee Schedule Data Base (MPFSDB) and/or the Evaluation and Management Documentation Guidelines manual.

• 4

  Review the medical chart, diagnosis book, HCPCS manual and procedure book to determine the appropriate modifier (normally 25) that indicates that the office visit was not related to the minor surgery, if it indeed was not.

• 5

  Record the demographic data for the patient and provider, the health insurance member ID, health insurance address, diagnosis, procedures, charge amounts, etc., onto the HCFA 1500 form or other billing claim form.

• 6

  Submit the claim form to Medicare.