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MOD 25 usage by dermatologist

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established patient, derm performs full body or sometimes upper body exam, does cryo and documents that patients old (not from a recent visit) melanoma scar is/has healed nicely. Scar is usually locate in same area of body as cryo.

Bill procedure and E/M with 25 modifier.

I say no E/M.

What do you say.

Evan Sade, CHC, CPC
 

cgifford

Contributor
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You state a full or partial body skin exam was done, was this documented? If it was not documented then it wasn't done. But if the full body was done and documented then I would bill the E&M with the Cryo but again the body skin exam would have to be documented in order to consider that.

Colleen, CPC,CPCD,CPB
 
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CatchTheWind

True Blue
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I agree. A full skin exam is a billable service as long as there is a "history of skin cancer" diagnosis (not just preventive visit).
 

az2tn@yahoo.com

Networker
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E/M global or bundled?

I agree. A full skin exam is a billable service as long as there is a "history of skin cancer" diagnosis (not just preventive visit).

I'm doing a derm audit. My first one and I'm confused. And I don't code for derm either. So this is all new to me. The edits I'm getting are saying an E/M on the same day as UVB therapy, cryotherapy, biopsy is either bundled or they are in a global and some of these patients are coming in for a skin check with a hx of basal cell, squamous cell and melanoma and then something is found and it is addressed at the visit with a procedure. Could someone point me in the right direction for some official guidance on an E/M being supported if a full skin exam is done? And are we talking a comprehensive skin exam 97 guidelines? Thank you :)
 
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E/M global or bundled?

Hello az2tn@yahoo.com,

I just recently did a few derm audits as well; if the patient presented and was scheduled for the minor office procedure(s) than a separate e/m should not be billed unless it is for a different problem/DX. If the patient presented for their TBSE (Total Body Skin Exam) and say seborrhic keratoses was found and cryotherapy was performed than you would bill the e/m service with modifier 25. If the e/m or minor procedure performed within a global period than you would need to make sure the appropriate modifiers were on the service(s).

As far as the e/m auditing I did follow the 1997 Dermatology Specialty Exam Guidelines. In order to support a billable e/m service the provider would need to do more than only perform a full skin exam. If the patient was established (where I audit) the medical decision making is always one of the two key components used to level out the service. If a new patient the documentation would have to support all three key components (history, exam, medical decision making) to level the service.



I hope this has somewhat helped clarify :)
 
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JesseL

Expert
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Per some sources, https://www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/Modifier-25-Primer-Use-It-Dont-Abuse-It.aspx

and https://www.medicaleconomics.com/category-47287/everything-doctors-need-know-about-modifier-25

To bill modifier 25:
The E/M service must be significant. The problem must warrant physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.

So it seems if the separate problem is too minor, modifier 25 is not billable.

I do disagree with this though...
 
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