Wiki I&D and E&M, modifier 25 or not?

[JesseL]

Haven't been sure of this for a while and want other opinions.

If a patient comes in and has a inflamed cyst for the first time, the provider does a I&D and send the contents to culture and wrote two prescriptions such as antibiotic pills and antibacterial ointment, does the culture and writing the prescription qualify as a separate E&M from 10060?

 

[CodingKing]

I don't see enough for an E&M. Everything is directly related to the I&D. All surgical procedures have a minor E&M component built into the global payment.

 

[JesseL]

What about this case?

New patient presents with Genital warts. Patient had this treated via laser last year by a different provider.

Detailed history revealed patient has hep B and admits to have difficulty breathing due to smoking and is on antibiotics for it.

Skin exam was performed on head (including face), neck, right upper extremity, left upper extremity, right
lower extremity, left lower extremity, eyelid, lips, and penis.

Provider educated patient on HPV and that it is a sexually transmitted disease

Provider prescribed Podofilox 0.5% topical solution and applied liquid nitrogen on 15 warts.

Patient mentioned he wants to get circumcised, provider advise to wait until warts are clear.

Patient also concerned about brown spots on his genitals, provider says they're benign.

Would this be 54065 only or 99201/99202 with 54065. I personally don't understand the need for the other body areas examined other than the genitals but the provider documents this.. Maybe to see if the patient has other warts?

 

[Kolbysmom08]

Need more information

In the first example we need to know if it is an established patient or new patient. If it was a New pt you have enough information to have an EM( with a 25 modifier) and the I&D. In the second case we need to know the location on the warts. As in real estate it is all about location location location.... If the genital warts are not on the penis itself then that is not the right code, or if they are on multiple locations including the penis you are under coding.. If the warts are on the penis and the supra pubic you can bill out an 17110( with a 59) along with 54065 and the new pt EM.. Remember for a new pt , you have a lot of work ( pt history and family history) which are not included in an established pt visit and not included in the destruction code.

 

[CodingKing]

Don't be so fixated on new vs established. It has no bearing whether an E&M can be separately coded. If the E&M would not have been separately reportable on an established patient its highly unlikely it would be separately reportable for the new patient under the same circumstances.

Per the NCCI Manual

If a minor surgical procedure (0-10 day global) 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 contains many, but not all, possible edits based on these principles.

you have a lot of work ( pt history and family history) which are not included in an established pt visit and not included in the destruction code.

The question is the H&P + Exam medically necessary based on the nature of the presenting problem. You could do a comprehensive exam on a patient with a paper cut but its completely unnecessary and does not count.