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Minor surgical procedure and E/M

  1. #1
    Default Minor surgical procedure and E/M
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    Looking for coding opinions:
    I have advised a doctor that when a patient presents for a wart removal, it is not appropriate to code/bill 99212-25 with 17110. There is not a significant, separately identifiable service to support using the 25 modifier.
    Then he asks me this:
    "What if I evaluate but then schedule the minor procedure for a different day? Then is the E/M service separately billable?"

    I am thinking this would not be appropriate as a way to get reimbursed for the E/M which is included in the minor surgical procedure.

    I would greatly appreciate others' coding opinions.
    Thanks in advance!
    Rebecca Johnson, CPC

  2. Default
    My opinion is that splitting the services would be OK

    One scenario I can think of is the doc see a walk-in at 4:45 for foot pain and sees a wart which can easily be removed, but there is no time to get the tray or the liquid nitrogen ready, so the patient is rescheduled for 10 a.m. the next morning

    I also would like to hear from other coders who work through more minor surgeries than I see

  3. #3
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    I would agree with the first post (and disagree with the previous post) that scheduling the procedure for another day in order to bill the E&M is not appropriate. The work of the initial evaluation and decision to perform a minor surgery is included in the value that is assigned to that procedure. Whether it is 'unbundled' by using a modifier on the same day or by scheduling it on a different day is irrelevant since both of these are inappropriate ways to try to bypass payer reimbursement policy to get additional payment . Also keep in mind that the standard definition of medical necessity is that the services are required for reasons other than the "convenience of the patient or provider". If the only reason the patient is rescheduled is because of time constraints in the provider's schedule, or to get a higher payment for the provider, then it would not qualify as a medical necessary reason for a separate service.
    Last edited by thomas7331; 08-22-2018 at 06:12 AM.
    Thomas Field, CPC, CEMC

  4. #4
    Default
    This was added to the NCCI manual, in 2017 i believe

    Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits
    CRC (2018), CPC-P-A (2016), COC-A (2016), CPC-A (2015), PAHM (2010)
    Contract/Fee Specialist - Remote

    20 years health insurance experience: Audit, Claims, Customer Service, Payment Policy, Provider Relations, and Reimbursement

  5. #5
    Default
    Thank you all for your input it is very much appreciated!

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