Wiki 11606 with 99214

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baroquecoder

baroquecoder

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Patient's chief complaint is 'presents for removal of lesion'
HPI: lesion present for 3 months and growing
ROS
EXAM
Lesion removed
impression;
BCC
not sent to pathology
not confirmed as BCC
Since the patient presented for the sole reason of having the lesion removed, and the procedure was reasonably anticipated, I do not think this E/M situation is warranted.
Furthermore, I don't believe this can be accurately coded without a pathology report.
I would code this to a lesion of the skin: L98.9 until pathology confirms.
Please advise on the issues I have raised here, primarily ordering an E/M with a minor procedure when the procedure is planned or reasonably anticipated.
Thanks.
 
Based on the information you've provided you are correct, the E&M code is not warranted. Per CMS global surgery guidelines, "The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed." You would not have anything to support a modifier 25 in this instance. I would also agree that the coding should be held for pathology results - it would not be appropriate to code a malignant diagnosis without a pathology report, but I would not use L98.9 as some payers may not allow the CPT for a malignant lesion excision without the malignant diagnosis - it's been my experience that it's a better practice to wait for the report and avoid having to submit corrected claims.
 
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You may want to have the group review E&M leveling practices as well. Absent of the procedure it would barely qualify for a 99212
 
Thanks Thomas!

thomas7331 said:
Based on the information you've provided you are correct, the E&M code is not warranted. Per CMS global surgery guidelines, "The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed." You would not have anything to support a modifier 25 in this instance. I would also agree that the coding should be held for pathology results - it would not be appropriate to code a malignant diagnosis without a pathology report, but I would not use L98.9 as some payers may not allow the CPT for a malignant lesion excision without the malignant diagnosis - it's been my experience that it's a better practice to wait for the report and avoid having to submit corrected claims.
Click to expand...

Thank you sir! What a great resource to have here in this forum!
I'm not sure how I'm going to remedy this situation as it is a frequent offense.

Thanks for your time!
 
11606 with 99214 with L57.0, Z78.0 and Z12.11

So doctor responds in disagreement claiming because he addressed Z78.0 by ordering a Dexa scan and Z12.11 by giving the patient cologuard test combined with the ROS with Comprehensive Exam qualifies as the 99214. Are there any good resources for E/M leveling when minor procedures are planned or anticipated that I could share with this doctor? To me, an ROS and Exam, does not an E/M make. This is a recurring issue. I have to deal with this in another way besides queries, he just disagrees. Patient's are coming in for reasonably anticipated procedures, slap on a pasted ROS, and pasted examination, slap on some historical conditions and or screening tests and voila, you have an E/M? I don't think so. Thanks for the help.
 
You didn't indicate you did a comprehensive exam. According to the Chief Complaint, there was one complaint for removal of the lesion.

Why was a comprehensive exam warranted? Personal history? Your example text mentioned nothing of this,

Regarding a "comprehensive" exam... Did the doctor REALLY do all 12 areas of the skin exam bullets and plus all of the Constitutional, eyes, Ears, Cardiovascular, GI, Lymphatic, Psychiatric/Neurological as warranted for a true Comprehensive Exam according to the 1997 guidelines???

Ordering of the 2 tests still makes Medical Decision making Minimal Risk.

But your doc is making the biggest mistake.

CPT 11606 is a minor procedure and the E/M related to the decision to perform it is INCLUDED in the E/M itself and cannot be billed for separately. An E/M can be billed for a separately identifiable or unrelated issue. Your chief complaint and example mentions nothing of this.

On the National Correct Coding Initiative Edit Guidelines, it states...

"If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles."


What this is saying is that the Evaluation and Management required to address the patient's specific chief complaint(s) is included in the reimbursement for the billable minor procedure. This would include determining the chief complaint(s), taking or updating history, review of systems, examining the patient, past family/social history, diagnosing the problem, ordering labs and tests related to the problem, making the decision on how to treat the problem, informing the patient, obtaining consent, and providing postop instructions. In summary, none of the aforementioned tasks/processes can be billed for separately if they are related to a billable minor procedure.

As an auditor of claims, unless it was clearly documented the medical necessity for doing so, I find it difficult to believe that a separately identifiable E/M was done if the chief complaint was that they patient presented for the removal of a lesion.

I will message you about some resources...
 
99214 + 11300, 99204 + 17000, etc..,

Thank you ellzeycoding!
I will keep an eye out for some resources. I really need to educate this doctor on the potential for fraud when ordering these Full E/M services with these anticipated procedures. I write extensive queries with great detail and I don't even think he reads them but responds in disagreement.
I agree with your findings. Regards the comprehensive exam, it's an 8 organ system exam and it's the same for every patient, he does them no matter what the chief complaint is. There never is any HPI. The only historical context is given as a diagnosis code in the impression; i.e. Z85.828, history of basal cell carcinoma. The doc also sometimes puts diagnoses that are present in the patient's problem list that he himself is not treating or addressing but he lists them in the 'impression/plan' to look like the encounter has a higher acuity. (I think) This doctor is an auditor's dream! There is also discrepancies between ROS/EXAM and the impression/plan.
 
Distinct, Separate and identifiable E/M, Modifier 25

I believe this is the crux of the problem. What exactly constitutes a 'distinct, separate and identifiable' E/M? Is it simply the performance of an ROS and EXAM above and beyond the minor procedure that qualifies as an E/M? I don't think CMS and the OIG have made this abundantly clear. They have also further muddied the definition by stating that this may or may not be the same diagnosis as the procedure to qualify for the distinct E/M. I have read some periodicals from the American Orthopaedic Society that states an E/M IS anything above and beyond what would normally done in a pre or post op situation, so stamping a comp ROS and Comp EXAM onto a minor procedure would qualify it. It doesn't make sense to me. This issue is of great importance to me. I'd love more discussion on this. Thanks for all who comment!.
 
The medical necessity for doing so is what carrier auditors look at.

If an established patient comes in for a complaint of warts on the hand, why is it necessary to do a full-body exam, take a detailed review of systems, etc.

Padding the note with blanket ROS and Exam (not warranted, medically necessary, or relevant to the CC) is padding the claim and is FRAUD. Ask the provider if he likes wearing orange jumpsuits?

An auditor's dream yes...

There is good info here frmo the recent Comparative Billing Report. I sent this to you and other links via private message...

https://www.cbrinfo.net/node/336

Read the Webinar Questions and Answers...

Also. a lot of valuable information in the NCCI Edits policies...

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/NCCI-Policy-Manual-2018.zip

Look at General Policies, page I-17 or

Look in Chapter 3 around Pages III-3


Some general tips...

1. An E/M that leads to the decision to perform a minor procedure is included in the minor procedure
2. An E/M for a separately identifiable issue (unrelated to the decision to perform the minor procedure) is billable. Sometimes this is for a completely separate problem.
3. An E/M for other issues that don't result in a a procedure is billable, as long as the documentation can stand alone and justify the level of care billed
4. You cannot count the E/M components related to the decision to perform your minor procedure as part of the separately identifiable E/M. You have Medical Decision Making (the procedure, labs, etc. related to the decision to perform the procedure). You can't count that MDM for your separate E/M. It's included in the procedure.
5. Medical necessity is the key!
 
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E/M lesion removal same date question

I would like to hear how everyone is handling the following scenario when coding/auditing for E/M services billed on the same date as a lesion removal, or other minor procedure.

You have reviewed all documentation and have determined that a a separately identifiable E/M is indeed medically necessary and appropriately documented. When assigning the E/M code, do you (a) disregard all documentation (history, exam and MDM) portions that pertain to the procedure, or (b) use all documentation to determine the E/M level?
 
jennyaharvey said:
I would like to hear how everyone is handling the following scenario when coding/auditing for E/M services billed on the same date as a lesion removal, or other minor procedure.

You have reviewed all documentation and have determined that a a separately identifiable E/M is indeed medically necessary and appropriately documented. When assigning the E/M code, do you (a) disregard all documentation (history, exam and MDM) portions that pertain to the procedure, or (b) use all documentation to determine the E/M level?
Click to expand...

A) you need to disregard
 
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