165.982 Changes in the Bundling of Medical Services by Managed Care Plans:
It is MSSNY’s position that when a patient sees a physician for evaluation and management of an illness, whether primary care or consultation, and the physician also performs a procedure which helps in the diagnosis or treatment of that illness, the physician should be paid for both the evaluation and management code and the procedure code. When a physician sees a patient to perform a pre-scheduled procedure, cognitive services are considered part of the performance of the procedure and the physician should be paid only for the procedure. The supporting rationale for this policy is embodied in two separate functions; (a) the evaluation of the problem and decision to perform a procedure; and (b) the performance and interpretation of the procedure. These functions could often be performed on separate days, but, for reasons of good medicine, expedited care and patient/physician convenience, it is often preferable to perform the procedure on the same day as the evaluation and management visit. It would, therefore, be inappropriate under these circumstances to either unnecessarily require the patient to have the procedure performed on another day or to deprive the physician of equitable payment for the proper provision of both services on the same day. (Council 12/19/96; Reaffirmed HOD 2000-257 & 268; Reaffirmed HOD 2014; Reaffirmed HOD 2024)
