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11402 billing with a 99214 on same date of procedure.

  1. Default 11402 billing with a 99214 on same date of procedure.
    Medical Coding Books
    My physician wants to bill a 99214 with a modifier 25 along with 11402.

    99214,25
    11402

    It is my understanding that an E&M code is already included in the 11402 on the same date of service as the 11402. There were no other diagnosis discussed and the only procedure preformed was the 11402. Am I reading the CPT surgical package definition incorrectly?

  2. #2
    Default
    If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

    For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

    99213-25 719.46
    11402 239.2

    Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

    Unless the excision was planned before the day of the visit, I'd bill the office visit as well.

  3. #3
    Location
    Everett, WA
    Posts
    886
    Default
    Also, carefully check your LCD's if this is MCR for accepted diagnosis codes. We had one just recently deny due to this.
    Suzanne E. Byrum CPC
    Noridian
    NGS

  4. #4
    Default
    I would not bill it with a separate E/M since payment for the excision includes the evaluation of the lesion. If the provider did no more than that then a separate E/M should not be billable.

    http://www.aad.org/dw/monthly/2013/j...t-two#allpages

  5. #5
    Default
    Quote Originally Posted by philipwells View Post
    If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

    For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

    99213-25 719.46
    11402 239.2

    Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

    Unless the excision was planned before the day of the visit, I'd bill the office visit as well.
    Even with this example I believe a separate E/M is not payable because the provider had only examined the area of the lesion and nothing else so only the excision will be payable because evaluating the lesion is included in that payment. It might be considered fraud to report the e/m with a symptom diagnosis when it's related to the procedure.

  6. #6
    Location
    Columbia, MO
    Posts
    12,913
    Default
    Quote Originally Posted by philipwells View Post
    If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

    For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

    99213-25 719.46
    11402 239.2

    Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

    Unless the excision was planned before the day of the visit, I'd bill the office visit as well.
    First, an excision cannot be billed without the path report as you will not know if it is benign or malignant until the path comes back,
    The 239 dx codes cannot be used until after the provider states this is a tumor or a growth, the definition in the code book states the term "mass" ( in quotes that means as well as similar terms) is not to be regarded as neoplastic.
    If the patient did present with pain at the site of the skin abnormality you would not use the 719.4- code as that is a musculoskeletal code.
    Also you cannot use the symptom to support one thing and the definitive to support a different part. The guidelines state that once a definitive dx has been rendered you do not code the symptom.
    The 25 modifier states that it is not required that you have two separate dx codes to support its use.
    The documentation must support that the provider examined the patient over above and beyond what was necessary for the procedure in order to bill the visit level and the procedure, the information provided by the poster here does not support this, you should bill the procedure only, after the path report is returned.
    Last edited by mitchellde; 09-27-2014 at 09:46 AM.

    Debra A. Mitchell, MSPH, CPC-H

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