Wiki Separately identifiable E/M?

[tag60]

I'm not sure if I should code a separate E/M visit for this encounter or just the procedure. I guess because the diagnoses are so closely related, I'm unsure:

Pt presents with warts and is also concerned about a mole and would like referral to dermatology. Exam reveals warts and a hyperpigmented irregular nevus. The warts are treated with liquid nitrogen and a referral is made for the nevus/mole.

078.10, 17110
448.1 (E/M with modifier 25 associated with this diagnosis or is it included above?)

Thanks in advance!

 

[emcee101]

A couple of important points:

1.) A separate diagnosis is not needed to bill for an E/M with a proceudre, as long as the E/M is significant and separately identifiable from what would normally be performed during the perioperative course of the procedure.

2.) It's not what was done, it's what was done AND how it is documented! The doctor should ideally have two separate notes that could each stand alone as a distinct service if the work was done to support billing for poth the procedure and the E/M.

- Is a quick discussion for the doctor to give the patient a referral for the mole really a significant service that would warrant an E/M code?
- Did your doctor do a workup for the mole and document this as the would a stand alone encounter?
- Would the patient have presented to the office if they did not have the warts just to get the referral for the mole?

I don't have the answers to these questions, but these are the types of questions I think about and ask my doctors when they are billing both codes. If the answer is no to most or all of these questions, then you may want to hold off billing the E/M with a 25 modifier.

(Side note: I just caught my wife's doctor trying to bill a similar scenario for a recent visit and was able to have it successfully reversed through the compliance dept. when their documentation did not support the E/M being billed! Being a coder saved us a $30 copay on top of the deductible from the procedure!!!)