Wiki Incidental Findings and modifier -25

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ndebien

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In a recent webinar the speaker brought up the inability to bill a separate E/M for incidental findings (not related to complaint from patient). Does anyone have additional information or resources to support this?
 
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Ndebien
If a Est or New patient arrives for treatment and they have ongoing issue or news medical problem and provider assigns meds this would be the primary dx code. However on treating the patient something else is discovered maybe a skin problem, UTI, cut on foot, or new medical problem treated same day this can be given more you should add dx codes in order of treatment importance. Actually the provider would give you list of dx codes. You only add modifier 25 if the patient gets additional ancillary services...injection, xray, bx, medical procedure or counseling or laceration repair for new problem. Then you can add modifier 25 to the Eval mgnt cpt code. Documentation considers that there needs to be evidence in the body of the record the condition required increased clinical care or monitoring during the admitted episode in order for the condition to be coded & add modifier 25. Also if patient comes in for let us say flu or sore throat or pain in leg then same visit physician checks her he finds out she maybe pregnant to, last dx code can be Z33.1 Incidental findings for prego lady..

If pt gets xray or lab and it is "abnormal" per the results from pathologist or radiologist see dx block R90-R94.Usually these providers will document abnormal lab or xray results or definitive dx.
I hope helped you understand difference in abnormal results vs incidental findings.
Lady T
 
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TThivierge said:
Ndebien
If a Est or New patient arrives for treatment and they have ongoing issue or news medical problem and provider assigns meds this would be the primary dx code. However on treating the patient something else is discovered maybe a skin problem, UTI, cut on foot, or new medical problem treated same day this can be given more you should add dx codes in order of treatment importance. Actually the provider would give you list of dx codes. You only add modifier 25 if the patient gets additional ancillary services...injection, xray, bx, medical procedure or counseling or laceration repair for new problem. Then you can add modifier 25 to the Eval mgnt cpt code. Documentation considers that there needs to be evidence in the body of the record the condition required increased clinical care or monitoring during the admitted episode in order for the condition to be coded & add modifier 25. Also if patient comes in for let us say flu or sore throat or pain in leg then same visit physician checks her he finds out she maybe pregnant to, last dx code can be Z33.1 Incidental findings for prego lady..

If pt gets xray or lab and it is "abnormal" per the results from pathologist or radiologist see dx block R90-R94.Usually these providers will document abnormal lab or xray results or definitive dx.
I hope helped you understand difference in abnormal results vs incidental findings.
Lady T
Click to expand...
I appreciate the response, but it doesn't really answer my question. I don't have a question of "what is" an incidental finding. My questions is that when an incidental finding is added to a chart in an attempt to bill out a separate E/M. My niche is dermatology, so for example: patient comes in for a biopsy of a specified lesion, but then the provider decides to "evaluate" an unrelated spot and says, "oh you have a freckle on your left shoulder. Don't worry, it looks to be benign, we'll just watch it.." In my coding/billing mind, that does NOT warrant a separate E/M. Dermatologists all over do this. I attended an AAD webinar where they advised this will cease being reimbursable, but of course didn't provide a source for confirmation.
 
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I think it depends on the context of the topic in the webinar. I always take webinar advice with a grain of salt. If they are telling you something but they do not provide any backup or reputable sources, I would do my own research.
In your example, that would not be a separate E/M in addition to the biopsy. It appears that the patient was presenting for biopsy as the sole purpose of the visit. Especially if the provider saw the patient for an E/M, scheduled them to come back for the biopsy and then suddenly sees a "new issue" that was not noted prior and it was just an "oh by the way" type.
Now, if it was the same scenario yet the patient had a new problem, a full workup was done in addition to the biopsy, that *might* warrant a separate E/M depending on the documentation. It is always going to be encounter and documentation specific. It has to be looked at from the perspective of meeting modifier 25 or not if it is a minor procedure (0 or 10 day) or modifier 57 (90 day unlikely in derm office setting).
They could have been talking about certain carriers that have a policy where they absolutely will not pay an E/M with or without a 25 on the same day as a minor procedure.

You have to ask yourself, if I cross out everything related to the minor procedure (pre, intra, post service work) is there enough or anything left to warrant a separate E/M with Modifier 25?

It's an active item on the OIG work plan for very good reason.

Old date but good info. https://cdn.mdedge.com/files/s3fs-public/issues/articles/CT095020076.pdf

From AAD 2021: https://sdnp.memberclicks.net/asset...ier_25_Educational_Tool_FINAL_01.21.21_v4.pdf
 
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