Dermatology Coding Alert

Published on Wed Oct 26, 2016 PDF

Use modifier 25 on E/M when you prove separate service.

Let’s say a patient comes to the office and complains about an embedded splinter, and the encounter meets the coding definition of foreign body removal (FBR). In this situation, you’ll likely choose the proper FBR code and call it a claim.

Exception: If the patient has less information up-front about his problem, however, your dermatologist might have to work harder to decide just what the problem is. When the dermatologist has to perform a service to pinpoint the problem, and then provides an FBR service, you might be able to report a separate evaluation and management (E/M) service in addition to the FBR code.

In order to report an FBR and a separate E/M code, “you would need to clearly illustrate that the [E/M] visit was separately identifiable,” explains Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, of ACE Med Group in Pittsburgh, Pa.

There are many reasons there might be a separate E/M before the FBR, experts say. Perhaps the patient didn’t know of the FBR, and the E/M was necessary to determine what was causing the pain. After an E/M determined that there was an FB, the next step would be to remove it, Hauptman says. “Thus, both services are codeable,” she continues.

Also: You might be able to code an E/M separate from an FBR service if the E/M addresses a completely unrelated problem or if there are, or may, be other injuries involved that the physician needs to address and possibly treat, explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC,  internal audit manager with PeaceHealth in Vancouver, Wash. Consider this example of a possible E/M-FBR scenario from Bucknam:

A patient presents with complaints of a metal splinter embedded in his right palm. Since the injury occurred four days ago, he has tried to remove the splinter himself, which has only caused it to embed deeper into his dermis. The physician cleans and examines the hand, decides that an incision will be necessary to remove the splinter, and proceeds to incise the FB site and remove the splinter. The procedure requires no sutures, and the excision does not pass the dermis. The physician then bandages the wound and gives the patient postoperative care instructions and medication prescriptions.

In this instance, you would likely be able to report an E/M in addition to the FBR code. If you can identify an E/M separate from the FBR, you would report:

• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR
• The appropriate E/M code based on encounter specifics (99201 [Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…] through 99215 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a compre­hensive examination; medical decision making of high complexity…])
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to the E/M code to show that the E/M was a separate service from the FBR.
• S60.551 (Superficial foreign body of right hand) appended to 10120 and the E/M code to represent the patient’s splinter.