AAPC - Back to school
Results 1 to 5 of 5

Thread: Examination Question

  1. #1

    Default Examination Question

    AAPC: Back to School
    If, on a new patient visit, the provider sees a patient for a laceration and documents the complete history, then under examination notes "Wound treatment/repair: 2.5 cm superficial oblique laceration of the dorsal aspect of the right distal phalanx of the thumb...wound appears clean, no visible foreign bodies, skin margins regular. Neurovascular exam intact, sensation distal to the wound intact, circulation intact, motor function intact. On direct inspection there is no tendon involvement. After cleansing wound was anesthetized with 1% lidocaine locally. Wound scrubbed w/Hibiclens. Six 5-0 inturrupted simple ethilon skin sutures were placed. Sterile dressing applied and wound bandaged.

    Provider wishes to bill new patient visit w/mod -25and surgical repair.

    Do you count examination elements noted within the wound treatment section or does there have to be a distinct separately documented examination?

    Is there a definition somewhere denoting what is considered "inherent" to a procedure?

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Minor Surgeries and Endoscopies Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

    So...in a nut shell, a minor surgery includes an inherent E/M component. When trying to decide if an E/M service is separate and significantly identifiable, look for documentation that sets your E/M apart from your minor procedure.

    40.1 C


  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default New patient exempt from Mod 25

    Actually NEW patient visits are exempt for the mod -25. You don't need the modifier because there is an inherent understanding that a new patient requires some evaluation.

    As for your documentation ... I'd phrase it differently ... the procedure needs to be clearly and separately documented from the E/M.

    If your entire "exam" documentation is the procedure, then you don't have an E/M.

    F Tessa Bartels, CPC, CEMC

  4. #4


    Thanks again FTessaBartels! Always helpful!

  5. #5
    Join Date
    Apr 2007
    North Carolina



    I will have to respectfully disagree with you on the use of modifier 25 on a new patient visit. I've done a great deal of research on this and that was Medicare's mentality years ago. Some Medicare contractors might follow this rule of thumb but I can tell you that our carrier will deny our E/M without this modifier. Unless you can show me differently (Not an individual contractor), CMS doesn't have this verbiage any longer.




Similar Threads

  1. E&M Physical Examination Question
    By skeledjian in forum Compliance General Discussion
    Replies: 0
    Last Post: 08-02-2012, 04:20 PM
  2. Examination Levels question
    By FWeber in forum E/M
    Replies: 0
    Last Post: 06-25-2010, 04:32 PM
  3. CPT 88300 (Gross examination only) question
    By mcandia in forum Pathology & Clinical Laboratory
    Replies: 1
    Last Post: 09-14-2009, 09:52 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.