Wiki E/M and Surigcal Package

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hcromwell

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I have a question related to the surgical package for minor procedures. CPT states "Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)"

Patient schedules for a painful lump in arm, patient is seen by one of the family practice providers, he does a expanded HPI, expanded exam, and prescripes antibiotic for abscess and decides that he needs to do an incision and drainage with packing.

99213-25 and 10061

or just 10061?

thank you! Heather
 
If all they came in for was an I&D (i.e.. it was scheduled previously) then you would code just the I&D.

If you have a separate and significant EM (i.e.. clear history, exam and MDM documented) in addition to a procedure note for I&D you should be able to bill both with a 25 modifier on the EM code.

It sounds to me your physician had and EM + a procedure.
 
hcromwell said:
I have a question related to the surgical package for minor procedures. CPT states "Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)"

Patient schedules for a painful lump in arm, patient is seen by one of the family practice providers, he does a expanded HPI, expanded exam, and prescripes antibiotic for abscess and decides that he needs to do an incision and drainage with packing.

99213-25 and 10061

or just 10061?

thank you! Heather
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He has an evaluation of the problem and then decides to do the procedure, this meets the qualification of the 25 modifier and the E&M can and should be billed. If the I&D had been scheduled prior to coming in and the provider performed an evaluation of the problem then it could not be billed as it is part of the procedure. When the medical necessity for the procedure has already been determined in a previous encounter and the procedure scheduled, then the day of the procedure any evaluation is a necessary part of the procedure, which is why it is included.
 
Walker let me try to clarify,
this is not different than if the physician had examined the painful lump then decided an I&D should be done and scheduled it for the next day, you would not object to the charging of the E&M and then the procedure. Or even like the physician that sees a patient and determines any surgicalprocedure should be performed and then schedules it for the future this would get a 57 modifier if the procedure has more than 10 days in the global.
Anytime the provider does not know the procedure needs to be performed and then decides after an evaluation that it does sets up the potential for the 25 modifier.
The poster stated an expanded exam was performed so without a note to go by I am assuming that this would be a significant exam and would allow for the 25 modifier.
However I will agree with you that if the exam were only what is necessary for the procedure then it would not be enough for the 25 modifier.
 
I guess it comes down to the definition of "necessary for the procedure" then. Based on my understanding of the global surgical package, which includes an office visit on the same day as a procedure, ANY office visit that is solely relatable to the painful lump would be bundled into the procedure. I see nothing here that makes the situation here separately reportable.
 
it does not have to be a separate diagnosis, but the evaluation needs to be signisifican as in over above and beyond the procedure. The procedure includes the examination of the affected area. But a significant and separate exam is one where the provider has not yet decided on a procedure or even which procedure, the affected area is examine but also the surrounding areas, organ or body systems, then the appropriate action is decided, by the poster stating an exp focused exam, I am assuming the provider did examine not just the painful lump, but a copy of the note would have been better to make the decision.
 
In the case you listed above, if you take out the elements pertaining to the painful lump and still had enough elements left to come up with a properly coded office visit, then I can see how a 9921x-25 would be appropriate. Thanks for your help :)
 
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