However, some Medicare carriers and many private insurers are bundling these services. The evaluation and management service does not have to be unrelated to the procedure and the same diagnosis is not sufficient reason to deny payment for the evaluation and management service. If the problem is with a Medicare carrier, the letter from HCFA should resolve the issue. In some cases with private payers, the letter may also have some influence because Medicare should set the minimum standard. Correspondence with the medical director of the payer in question becomes an important part of the process for solving this problem.
Medical records documenting the office visit as a separate service are crucial.
Frequently, medical directors agree with the ACR s premise but argue that rheumatologists don t adequately document the fact that the visit was separately identifiable. The payer may have a different idea of what constitutes adequate documentation than the rheumatologist does. Some payers insist on two separate ICD-9 codes. The physician should get, in writing, the payer s policy on documenting an office visit and an injection on the same day. The CORC Network can assist with taking the matter further if it is not satisfactorily resolved.