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Modifier 25, E/M and burn dressing

  1. #1
    Default Modifier 25, E/M and burn dressing
    Medical Coding Books
    This patient came back three times within a week for 2nd degree burn wound dressing. I've billed 16020 for the burn dressing for the first two visits.

    The third visit, patient has skin infection from the burn site. A culture was taken, and antibiotics were prescribed, and then wounds were re-dressed.

    Would taking a culture and prescribing antibiotics for the the burn wound be considered above and beyond what is usual for 16020?

    Should I bill 99213-25 with 16020?

    Thank you.

  2. #2
    Default
    Ran into this situation again, hoping for opinions.

  3. #3
    Default
    It's a little hard to say without seeing the whole note, but just based on what your post said, it doesn't sound like 99213-25 is supported. A culture and prescription alone is not enough to support 99213 - you also need to have either history or exam above and beyond what's involved for the wound treatment. Also, per CMS, as a 0-day global code, 16020 includes "includes all necessary services normally furnished by a surgeon before, during, and after a procedure" and includes the writing of orders. That would seem to me to include the culture and prescription.
    Thomas Field, CPC, CEMC

  4. #4
    Default
    Quote Originally Posted by thomas7331 View Post
    It's a little hard to say without seeing the whole note, but just based on what your post said, it doesn't sound like 99213-25 is supported. A culture and prescription alone is not enough to support 99213 - you also need to have either history or exam above and beyond what's involved for the wound treatment. Also, per CMS, as a 0-day global code, 16020 includes "includes all necessary services normally furnished by a surgeon before, during, and after a procedure" and includes the writing of orders. That would seem to me to include the culture and prescription.
    hmm.. Could you give examples of what would be considered extra work for same diagnosis with modifier 25?

    I would have thought treating the skin infection from the burn would be consider extra work from dressing the burn..

    The one I recently ran into is prescribing pain medication for pain from the burn because the patient complaint of pain, and also antibiotics and cultures were done along with dressing.

  5. #5
    Default
    16020 covers local care of the wound, so that would include the history and exam that is required for the wound care, plus any orders required related to that care. If the infection is documented as related and treated as a part of the wound care, then a separate E/M code is not supported. But if, for example, the notes suggest that the infection may be a more systemic problem or something unrelated that requires the physician to take additional history or examine systems or body areas separate from the wound itself, then you could defend the use of the modifier 25. It's really all based on documentation. Think of it this way - if you bill an E/M code and it's denied, do you feel you could write an appeal and point to exactly what parts of the documentation support a separate service? A culture and prescription could support low MDM, but MDM alone doesn't make a 99213 - there also has to be an expanded history or expanded exam that is separately identifiable too.
    Thomas Field, CPC, CEMC

  6. #6
    Default
    thanks, that makes sense

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