Wiki Does this support a separate E/M charge?

[sinman0531]

I'm auditing documentation/reviewing insurance denials to see if they are eligible for appeal. We billed a 99213 for a patient with a diagnosis of HS. Patient was seen 30 days prior and billed for an office visit then, which was paid.

This date of service the provider performed ILTAC injections into some of the lesions. The documentation for the "visit" is mostly cut-and-paste/automatically added by the EMR. The only original/unique documentation that has been added for this visit is:

"Flared today; worse with menses. Prescribed doxycycline 20mg PO to help with flares around menstrual cycle."

I'm conflicted as to whether that is truly enough to support a 99213 in light of also performing the 11900. If it were by itself, I would really advocate for a 99214.

 

[csperoni]

-25 is SIGNIFICANT, SEPARATELY IDENTIFIABLE evaluation and management service by the same physician on the same day of the procedure or other service.
Whenever waffling about billing an E&M with a procedure, take the documentation and cross out everything that was part of and related to performing the procedure. That gives you the "separately identifiable" portion. Then I decide if the leftover is "significant". I do not define significant as the amount of information, but rather the context of the information. It is right on the borderline here, but I would count that additional medical decision making work of deciding ongoing treatment with a prescription when flaring to meet the category for -25. There may be those who disagree.