ktrial, you can bill and E/M (with 25 modifier) and procedure, IF and ONLY IF documentation supports it. So, if the provider simply sees the patient to take off whatever type of lesion, they are correct in billing just the procedure to take it off. Yes, there would (and should) be an office note, with a review of the area in question, but that "is" inclusive of the procedure. Providers ALWAYS review what they're going to do. They're not going to simply see a dot/wart/lesion and excise it. They have to examine to decide what's the best way. However, IF they do something above and beyond that, that justifies an E/M with a modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service" .. then you can bill/code both. (linking dx's and modifiers accordingly).
It sounds as though your provider simply did the basics in the removal of the lesion.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join