Question Modifier 25 same day as minor procedure

bestdgevr@hotmail.com

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Hello,
I am in a dispute with my Pears and Physician on whether this consult 99242 should be billed with this procedure with a modifier 25. Below I have included the report for review.
Any help would be greatly appreciated.
Thank you,
Shana Parker CPC


Date of Service: 07/03/19 09:00

Chief Complaint

Procedure/Internal Hemorrhoids

History of Present Illness

I received a written request for consultation from Dr.Arteaga Falconi so I can render an opinion further work-up and treatment of a patient with hemorrhoids. Patient is a 23-year-old male who is noticed occasional prolapse of tissue. He has some mild discomfort at times. Very occasional rectal bleeding. He is actually looked at his rectum with the mirror and seen circumferential tissue all the way around.

PMH
Medical problem: None
Medication: None
Allergies: No known drug allergies

PE
General: Well-developed well-nourished 23-year-old male in no acute distress. Skin: Warm. HEENT: His sclera are anicteric. Neck: No swelling. Rectal: He has some mildly redundant perianal skin. There is no external anal pathology. Anoscopy to 5 cm demonstrated normal mucosa. There was a grade 1 internal hemorrhoid left posterior laterally. Rubber band ligation x1 was accomplished.

Assessment/Plan

1. Internal hemorrhoid K64.8
Internal hemorrhoids status post rubber band ligation

Plan
I suspect most of what he notices is rectal mucosa prolapse. This is most likely due to straining. He has no evidence for full-thickness rectal prolapse. He should avoid constipation. He should avoid straining. I discussed diet to include lots of fruits and vegetables as well as adequate hydration. He can return here on a prn basis.
 

nickelclaw

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46221 depends on the global days. This is the procedure I got not sure what you are trying to bill.
Guidelines for consult state that if a procedure is done that day or subsequent to the date of the initial consult then you code it. Hope this helps:)
 

bestdgevr@hotmail.com

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Thank you for your response, I understand the procedure can be billed and what the procedure is. my issue is that per the global guidelines regarding an E&M the same day as a minor procedure, states the consult would not be billable. I am in dispute with my pears and Physician on this one as they tell me this would be ok to bill with this minor procedure.
Any help would be greatly appreciated on this as this is an on going issue.
Thank you,
Sparker
 

Mayzoo

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I am still fairly new to coding, so hopefully someone else more experienced comes along.

Since it is not an established patient, I would put a 25 on it.

"You must, however, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service to differentiate it from the "inherent" E/M component of the other procedures (hemorrhoidectomy, scopes) provided on the same date. Therefore, your claim would read 46221 (for ligature hemorrhoidectomy), 9920x-25 (for the E/M service), 45300 (for proctosigmoidoscopy), 45330 (for sigmoidoscopy) and 45378 (for colonoscopy), Mueller says. "

 
Last edited:

thomas7331

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I do not believe that the E/M and modifier 25 is supported given the note you're provided above. Per the CMS global surgery guidelines, the "initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package." There is nothing documented in the note above that would constitute an evaluation above and beyond what would be included in the initial evaluation and the pre- and post-operative care normally and routinely associated with the performance of this procedure. What rationale are your peers or provider giving to argue that the documentation supports this?
 
Last edited:
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The Visit’s Purpose Can Help You Decide
Even if the E/M service is related to the minor procedure, you still may be able to report it separately. Ask yourself: Did the E/M occur because of the procedure, or was the need to perform a minor procedure determined as a result of a significant (i.e., fully supported by documentation and includes the key elements of history, exam, and medical decision making (MDM)) E/M service? Only in the second case may you report the E/M in addition to the procedure.

 
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