EM with Procedure

ktrial

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I am new to coding so I need all the help I can get. I am currently working at a family clinic and I asked one of the Dr.'s about an office visit. I was under the impression that if the Dr. did, let's say a skin tag removal, lesion destruction or sutures they could bill an OV with modifier -25. The Dr. tells me NO you can't. Insurance won't pay even if the OV has modifier -25.:confused:

Can someone enlighten me on this? Unless I'm not reading it correctly my CPT book doesn't really go into that much detail. Is there a website or another book that would be helpful to me?

I would appreciate any help and or suggestions.
 

dmaec

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ktrial, you can bill and E/M (with 25 modifier) and procedure, IF and ONLY IF documentation supports it. So, if the provider simply sees the patient to take off whatever type of lesion, they are correct in billing just the procedure to take it off. Yes, there would (and should) be an office note, with a review of the area in question, but that "is" inclusive of the procedure. Providers ALWAYS review what they're going to do. They're not going to simply see a dot/wart/lesion and excise it. They have to examine to decide what's the best way. However, IF they do something above and beyond that, that justifies an E/M with a modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" .. then you can bill/code both. (linking dx's and modifiers accordingly).
It sounds as though your provider simply did the basics in the removal of the lesion.
 

ktrial

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dmaec -

Thanks for that explanation, that makes sense to me. Okay what if a patient comes in with a laceration or needs a splint, could/would you charge an OV along with the procedure?

Is there somewhere I can find this information out or is it a process of doing and asking questions?
 

MANCODER

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Donna is correct, make sure the mod goes on the E/M code not the procedure. As she stated it must justify the fact the patient did not appear/schedule for that purpose
 

ktrial

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Thank you all for your help and suggestions. I really appreciate the quick responses. :)
 
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OV with splinting

You can bill the OV with a 25 modifier, the application code, and the HCSPCS code for the splint. Just always make sure you have all the documentation needed. The application code will cover a lot of the physician's work, so the office visit code needs to have documentation that the visit went above and beyond the normal "set and splint"
 

ktrial

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Thanks Lindsey -

This is all good information to know. I am going to assume that the same applies if someone comes in to get stitches. Since this is what the patient came in to see the Dr. for - I would have to have documentation that the office visit went above and beyond. I know there usually is no office visit when the stitches are removed. :) :)
 
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Stich removal = office visit

Thanks Lindsey -

This is all good information to know. I am going to assume that the same applies if someone comes in to get stitches. Since this is what the patient came in to see the Dr. for - I would have to have documentation that the office visit went above and beyond. I know there usually is no office visit when the stitches are removed. :) :)
Actually, when the patient comes in JUST to have the stiches removed (assuming it is outside the global period for the original laceration repair, i.e. > 10 days) you bill ONLY an office visit and no procedure.

F Tessa Bartels, CPC, CPC-E/M
 
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