OB/GYN office visit and I&D

dlgordon

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Street, Maryland
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We have a new patient who came into office for lump on labia. After
new pt work up an I & D was performed. The Dr did not use a well woman dx code only the problem codes, lump, pus and foliculitis for the I & D. Can this encounter be billed to Medicare using a new pt E & M code with a 25 modifier and the I & D code or just the I & D code. Thanks:
 

njlott49

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njlott cpc

If the patient was new you would need to bill with an office visit. Because your doctor made a decision to perform the I & D at that time you would need to apply the .25 modifier. You would also bill for the procedure using the dx codes you gave. Whether new or established, always use the .25 when the doctor makes a decision to perform a procedure on the same day. Hope this helps.
 
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