Question Modifier 25 same day as minor procedure

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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

Networker
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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:)
 
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