New patient office visit and procedure the same day

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Gilbert, AZ
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If you have a new patient that comes to the office of a complain of spot on their cheek that they want checked. The doctor does the appropriate history, exam, etc and decides to do a shave removal on the spot. Would you charge an office visit with a modifier 25 as well as the procedure or would you change an office visit with no moodier and procedure? The office office visit and procedure have the same diagnosis.
 

trose45116

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cincinnati
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if the decision to shave the lesion was based on after he did his review then i would charge the office visit. the doctor made his decision it seems like after. the diagnosis codes doesnt matter if its the same as long as the documentation supports the office visit with the mod 25.
 

CodingKing

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without seeing the full note, it sounds like standard pre-op to me. Decision for surgery only comes into play for major procedures. There is a minor HEM inharent in any procedure. THe E&M must be significant and separately identifiable for separate reporting. I could understand a separate E&M if it were an "oh by the way I also have this growth on my face can you look at it?" but if its nothing to see if the lesion needs to be removed, that is bundled.
 
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mhstrauss

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without seeing the full note, it sounds like standard pre-op to me. Decision for surgery only comes into play for major procedures. There is a minor HEM inharent in any procedure. THe E&M must be significant and separately identifiable for separate reporting. I could understand a separate E&M if it were an "oh by the way I also have this growth on my face can you look at it?" but if its nothing to see if the lesion needs to be removed, that is bundled.

I agree with this. There is info outlining this CMS's NCCI edits.
 
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