Separate EM or procedure only?

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Is this enough documentation to bill 99213-25 and 11055, or would it be 11055 only? I don't see any consideration of options and then a decision to do the callus trimming, but there was a separate exam, so I was thinking 99213 could be billed.
HPI
This is a 71 year old male here for followup.
Allergies: Hydroxyzine.

ROS:
HEENT: Negative
Respiratory: Negative
Musculoskeletal: Negative
Neurological: Negative

Exam:
General: Alert and oriented to person, place and time.

Vascular:
DP: Palpable Left 1, Right 1
PT: Pedal pulses palpable Left 1, Right 1
Pedal hair present bilaterally.
No edema, ecchymosis or erythema.
Skin temperature warm to cool proximal to distal bilaterally.
No varicosities/spider veins bilaterally.

Neurological:
Sensation intact to superficial and light touch to all nerve distributions of foot.
Sensation intact to 10 g monofilament bilaterally.
Deep tendon reflexes 2+ for patellar and achilles bilaterally.
No muscle atrophy noted bilaterally.

Skin:
Callus of plantar 4th digit left foot.
Open wounds absent.
No signs of infection.

Assessment/Plan:
Callus left foot. Trimmed with 11 blade.
 

trarut

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What was the patient "here for followup" for? What is the chief complaint, the intent of the visit? If it is to re-assess the callous to determine if it needed trimmed, no I don't think it warrants a separate E/M.
 
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OK, thanks. What if he had said "here for followup for routine foot care?" That's what he means, but he doesn't say it.
 

vinessachilders

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No separate E&M would be supported. The exam would have to be done for a complaint unrelated to foot care to qualify as a separate service.
 
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Lunap99

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A similar question, we do a lot of ingrown toenail removals. I have attached a visit note. The providers like to try to bill office visits with the nail removal. I don't think that there is enough here for a separate OV but I have been getting a lot of push back when I try to remove them. They are saying that they do a full exam but I feel that they are still thinking in the '97/'95 in E/M method. What do you guys think? If there is not enough, what could they add to get that separate OV that they want?
I also noticed that there is no CCI edit for 992XX and 11730. This just means that I don't need a 25 but they still have to document enough to support the E/M, right?
I have a feeling we are going to have a meeting between us coders and the providers on this topic and I need to be able to show them what a truly separately identifiable E/M looks like.
 

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csperoni

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A similar question, we do a lot of ingrown toenail removals. I have attached a visit note. The providers like to try to bill office visits with the nail removal. I don't think that there is enough here for a separate OV but I have been getting a lot of push back when I try to remove them. They are saying that they do a full exam but I feel that they are still thinking in the '97/'95 in E/M method. What do you guys think? If there is not enough, what could they add to get that separate OV that they want?
I also noticed that there is no CCI edit for 992XX and 11730. This just means that I don't need a 25 but they still have to document enough to support the E/M, right?
I have a feeling we are going to have a meeting between us coders and the providers on this topic and I need to be able to show them what a truly separately identifiable E/M looks like.
Not a podiatry coder, but....If you were to take that note and cross out any work related to 11730 (or 11750 which is what is in the note), I just don't see how you have a visit.
Also, when I run 99202-99215 with 11730 or 11750 through my Codify program, they do come up as CCI edits that may be overriden if appropriate. In this example, it would not be appropriate.
Examples of when it may be appropriate is if there was a separate issue evaluated and treated (hammertoe, ingrown nail on other toe that did not require removal, bunion, plantar fasciitis, etc.).
 
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