In a vivid reminder that preoperative assessments aren’t separately billable, Memorial Hermann Health System in Houston agreed to pay $6.4 million to settle a civil monetary penalty case about claims that included codes for the history and physical (H&P) and modifier 25. The settlement with the HHS Office of Inspector General (OIG) was signed around the same time that CMS finalized regulations that allow hospitals and ambulatory surgery centers (ASCs) to use an abbreviated version of the H&P before outpatient procedures.
According to the settlement, OIG alleged that from April 1, 2011, to May 31, 2017, Memorial Hermann Health System submitted claims to Medicare, Medicaid and TRICARE that automatically appended a 99201 or G0463 facility CPT code to preoperative assessments performed by nurses in a hospital setting and/or automatically appended modifier 25 to some evaluation and management (E/M) services billed on the same day as surgeries. Memorial Hermann Health System reported the problems to OIG and was accepted into its Self-Disclosure Protocol in September 2018. The health system didn’t admit liability in the settlement.