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Question: An established patient presents to a primary care office with worsening right knee pain that has limited walking for the past two weeks. The patient has known knee osteoarthritis but reports that the pain has intensified despite using over-the-counter acetaminophen. The physician reviews the patient’s recent knee radiographs, which show degenerative changes without an acute abnormality, and performs a focused examination that reveals joint-line tenderness and reduced range of motion but no instability. The physician assesses an exacerbation of osteoarthritis, prescribes topical diclofenac, recommends activity modification, and refers the patient to physical therapy.

While examining the patient, the physician also notices a painful, inflamed skin tag on the back of the patient’s thigh. The patient says it repeatedly catches on clothing and requests removal. After separately evaluating the lesion and obtaining consent, the physician removes it during the same encounter. Would this situation call for appending a modifier to the encounter code?

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Coding: Yes, 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) would be appropriate here, as the evaluation and management (E/M) of the knee pain is separate from the assessment and removal of the skin tag.

The exacerbation of a chronic condition and prescription drug management support moderate medical decision making (MDM), which may support reporting 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) with modifier 25 for the established patient office/outpatient E/M service when the record reflects the services described. Don’t forget to report the applicable procedure code for the respective skin-tag removal.

The note should clearly distinguish the history, examination, MDM, and treatment plan for the knee complaint from the assessment and procedural documentation for the skin tag. A different diagnosis is not required to support modifier 25, but each reported service must be supported by the provider’s documentation.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC