Wiki Podiatry established plan of care and E/M

[savealife07]

Hi. I am a relatively new Podiatry coder for a small Podiatry department in a relatively large healthcare system. We have one provider that ALWAYS drops an E/M code along with procedure code for established patients with established care of plan. Regardless if they are coming in for the ulcer that been there for years, an ulcer that's healed, hammer toes that have been addressed, ext. Their response is that "the plan of care for these patients can change every visit because the wounds change. That all needs to be evaluated and proper changes made at each visit". So, I've really had it today and spend time comparing documentation word for word - its almost identical, which is whatever, BUT I did not see a single new thing other then then "ulcer is healed". I was under impression if the issue is established and no changes are occurring, then the procedure code (today it was 11055) covers the minor explanations of the procedure and the outcome. What am I missing? Am I misunderstanding something? Or how do I communicate this effectively to the provider?

Thoughts anyone?
Thank you.

 

[heatherposchman1]

The E/M should not be reported since it bundles with the same day procedure per NCCI rules (EX: 99213, 11055) and to add the modifier 25 to override the NCCI edit, a "Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure" is required. I don't believe that "ulcer healed" would qualify for a significant separately identifiable E/M service on an audit.. Essentially appending the -25 to override the edit, if not supported in the note, is considered fraud.

 

[podcoder70]

You are not misunderstanding. To get paid for the 9921x with the procedure, you have to add the 25 modifier. In doing so, you are indicating that there was and evaluation and management component of the visit that was significant and separately identifiable from the procedure. In Podiatry, we see a lot of patients on a regular basis for calluses and nail treatments, in most cases, there is nothing that has changed, no evaluation of anything new, no management of a new complaint. The diagnosis on the e/m should be different from the procedure to properly add the 25 modifier. APMA has gone as far as to say that the notes should actually include the phrase "this evaluation is significant and separately identifiable" and documented in detail.

Most likely, your Podiatrist is a member of the APMA. Have him/her watch this webinar https://www.apma.org/applications/secure/?FileID=109604