E/M - Dermatalogy

michiboo

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I have a provider who always wants to bill an E/M with scheduled procedure. Wants to bill E/M 99211. Does this qualify for and E/M?? Please see the bottom of note. That is why provider wants to bill 99211. Need some advice please.



CS-20-0331

OPERATION: SURGICAL EXCISION OF CUTANEOUS MALIGNANCY USING
CONTINUOUS MICROSCOPIC CONTROL(MOHS MICROGRAPHIC SURGERY)

DIAGNOSIS: squamous cell carcinoma in situ 

LOCATION: left helical root

INDICATION FOR MOHS SURGERY: histologic type, location, indistinct clinical margin

ANESTHETIC: LIDOCAINE 1% WITH EPINEPHRINE

PREOPERATIVE SIZE OF LESION: 0.6cm
POSTOPERATIVE SIZE OF DEFECT: 1.0cm
ESTIMATED BLOOD LOSS: <10mL

PROCEDURE: Patient identified. Procedure verified. Site identified and verified and confirmed immediately prior to the procedure. Site marked. Thin layers of tumor-containing tissue were excised at each stage of surgery. These were cut into smaller tissue sections which were examined microscopically in a systematic fashion. Examination of the entire base and superficial peripheral margin allowed microscopic tumor extensions to be located and mapped. In accordance with the Mohs technique, this procedure enabled the maximum amount of normal tissue to be preserved while achieving the highest cure rate for cutaneous malignancy. At each surgical stage, the patient was prepped, the proposed excision outlined on the skin, and the area was reanesthetized as needed.

STAGE I: The patient was prepped and the area of surgery was outlined. The operative site was anesthetized with a local injection of lidocaine 1% with epinephrine. Following this the clinically apparent portion of the tumor was surgically removed. Hemostasis was achieved with an electrosurgical device. A thin layer of tissue was surgically excised and hemostasis was obtained. A reference map was drawn and the excised tissue was cut into 2 sections for examination in the micrographic laboratory. Edges of each section were dyed in order to achieve precise orientation. Horizontal sectioning of the base and continuous peripheral margins were then carried out and the prepared microscopic sections were examined by myself. 
At this point, no further tumor cells were identified and the tumor eradication was considered to be complete for a total of 1 stage of surgery in which multiple microscopic slices of tissue sections had been examined.

WOUND MANAGEMENT:
This wound was reconstructed with a complex linear repair. Local anesthesia was achieved with 1% lidocaine and epinephrine. The operative site was surgically prepped with hibiclens, then draped with sterile towels to insure a sterile field. Beveled wound edges were then excised to 90 degrees relative to the surrounding skin plane. Burow’s triangles were excised from the poles of the wound and oriented to use relaxed skin tension lines and anatomic borders to greatest advantage. Wide undermining performed (involving free margin) to allow for tissue movement. Meticulous hemostasis was obtained with the electrosurgical device. The wound was repaired in a layered fashion. Sterile pressure bandage applied; wound care reviewed.

The total area of repair was 3.2cm

Subcutaneous closure material: 5-0 monocryl
Cutaneous closure material: 5-0 fast

______________________________________________________________________________________________________________________________________________________________________________________________________
He is also concerned about rough spots on his arms.
Exam of forearms and hands completed.
AKs forearms and back of hands. Discussed tx options and risks. He will tx with efudex bid x 3w; reviewed how to use/risk; toxic to pets. Call with concerns.
 

cgifford

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He examined the area of concern, discussed tx options and risks and from the note even prescribed efudex so the doctor can bill and get paid for an e&m just be sure to use modifier 25, that it was a separate identifiable e&m same day as a procedure.
 

JesseL

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to my knowledge, 99211 are for nurse visits, generally should not be used for providers. At minimal they should use 99212 for a problem focus exam and straight forward medical decision making.

The problem also needs to be unrelated/separate to the surgery done on the same day to bill modifier 25. Also, the problem has to be significant enough to bill modifier 25, which means if the problem is so minor that it doesn't require a prescription or a return visit, it's not significant enough to bill modifier 25.

So if the provider cut out a lesion and afterwards the patient says "can you look at this mole" and the provider looks at it and says "it's benign," the problem is too minor to separately bill for.

That being said, I think your notes supports a separate E&M. Just not a 99211. Ak's should require treatment as they are considered precancerous so it's a significant and separate enough problem in my opinion to bill with modifier 25. The fact that the provider addressed it and prescribed something for it makes it separately billable.

The provider should not "ALWAYS" expect to bill a E&M for every procedure when there's not a separate or significant problem to bill for. Things like examining the lesion, cutting it out, and then prescribing antibiotics as prophylaxis from the surgery are all included in the codes for the surgery because these procedure codes have I guess you could say built in E&M in them.

 
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