Wiki More Office Visit with Procedure questions

[AprilSueMadison]

Well, maybe just one more. After this I'm so done. Again, I'm sorry...I'm just in a really bad position (still) and don't yet have the confidence to just say with 100% certainty that I'm not wrong.

New Patient.

CC: Lesion on nose

History component:
Four elements about the lesion on the patients nose.
Extended ROS
Complete PFSH

Examination component:
7 bullets. (Face, Left arm, Right arm, Left leg, Right leg, back, scalp)

Medical Decision Making:
Moderate (Undiagnosed new problem with uncertain prognosis).

Procedure:
One biopsy of the nose

According to the American Academy of Dermatology, a biopsy includes the following work:

Pre-operative Work:
Prior to biopsy of lesion, obtain pertinent history from patient to include: previous skin cancer, prior treatment history, sun protection history, etc. Discussion with patient will include: indication for biopsy procedure, risks, and benefits; description of biopsy procedure method, and expected result and/or scarring. In addition, patient agreement/informed consent is obtained and staff is advised for preparation of patient and necessary anesthetic, supplies, and instrument tray preparation.

Intra-Service Work:
Inspection and palpation of the lesion to assess depth and to select most representative site to obtain specimen. Cleanse biopsy site with suitable antiseptic; inject appropriate local anesthetic; apply sterile drapes; obtain skin specimen with scalpel, skin punch, or suitable instrument depending on depth and amount of tissue needed. Collect specimen in labeled formalin container. Undermine wound edges as needed to facilitate repair. Suture to approximate wound edges, or achieve hemostasis with pressure, chemical, or electrocautery, or application of topical hemostatic agents. Apply antibiotic ointment and sterile dressing.

Post-operative Work:
Instruction of patient and/or family on postoperative wound care, dressing changes, and follow-up. Patient advised how to recognize significant complications, e.g., bleeding, or allergic reaction to antibiotic ointment or adhesive dressings. Patient advised when results will be available and how they will be communicated; completion of medical record; and communication of results to referring physician as appropriate.

Now, to bill for an E&M, I need portions of this exam that go beyond what is normally included in the biopsy. So to find that out, I would cross out everything directly related to the biopsy.

That leaves me with the following:

History Component:
Extended ROS
Complete PFSH

Exam Component:
6 bullets. (Left arm, Right arm, Left leg, Right leg, back, scalp)

I need all three components to be met for a new patient (and it's required to have a CC and at least a brief HPI) ...therefore, I do not have a new patient office visit, correct?

 

[CatchTheWind]

Don't apologize; that's what this forum is for!

You are correct: No office visit.

The question is, why did the provider examine all those other parts of the body if there was nothing in the CC that indicated a need to do so? If the patient wanted a full skin check, there should have been a second CC (either "history of skin cancer" or "skin screening"). If the former, you then have a billable OV. If the latter, you've got an OV, but it's probably not billable, so you will have to either write it off or collect from the patient as a non-covered service.

There is an ongoing discussion about this at http://aapc.com/memberarea/forums/showthread.php?t=74176

 

[AprilSueMadison]

Thank you very much. I've spent a lot of time in the last week defending our new coding practices (we are now coding correctly).

They analyzed the data and of course our office visits are down when compared to last year. This is because last year, our doctors circled the E&M code they FELT they performed, and it was just blindly entered and billed by the receptionist. We no longer do that and have an auditor and myself involved.

I spent an hour last night trying to explain (for possibly the 10th time or so), correct coding and how office visits work. I had examples, articles from the AAD and more. Still...he was upset and I'm not for sure he understands still. I have a feeling I'll get through another three months and then have to go through this conversation again.

We use the history of skin cancer codes and generally have office visits when we use them. Our doctors ALWAYS try to do a full skin exam no matter if it is warranted or not. Obviously though, when they do this and give me no other info for an office visit...they technically lose money because they are doing the extra work for nothing.

Heading over to the other discussion now!

 

[Lynda Wetter]

This too is a problem for me to "prove"
A patient comes to be seen in an urgent care setting, has a laceration and the physician sutures the laceration. I feel the exams are usually pertnent and not beyond the normal for checking vitals and to see if for example an arm laceration that touch sensation is intact. Whether new patient or not I feel if nothing else was done we should not be chargeing a visit. Now if they do an x-ray or update a Tdap I am more inclined to charge a visit.

Most physicians feel the patient walks in and its an automatic visit.
Afterall that is what the 25 mod is for, right!
(I'm kidding about that by the way, LOL)

 

[AprilSueMadison]

Regarding your example CoderGirl, this is from the NCCI pdf in regards to the integumentary system.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure 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.

Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological an E&M service may be separately reportable.

Per the example, it seems like if they presented for the repair and received one, and all of the pre-work, repair and post-work were related to the repair...there would be no office visit. However, if during the repair they noticed forgetfulness or the patient mentioned it since the head trauma and did a neurological workup...there would be an E/M then.