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proper billing of services

  1. #1
    Default proper billing of services
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    I have a Doctor who always does an office visit with the paring or cutting of lesion (11055 or 11056). The e/m is never seperate so there isn't a 25 modifier applied. The question is, does the Doctor HAVE to bill the 11055 or 11056 if done with the e/m visit? The question is coming up because e/m gets bundled into service and is paid as a lower amount. Doctor wants to know if he can just bill out the e/m and not the paring or cutting of lesion. My thought is the service must be billed because it was done. Am I correct in my thinking? Any comments are appreciated.

  2. #2
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    If a code exisits for the service performed then that is the code you select. This is the way it was always explained to me. Why do you say the E&M is never separate? Was the patient scheduled to come in for the procedure? If so I agree no E&M should be charged. However if the evaluation is over above and beyond the evaluation needed just for the procedure then you should have the E&M with the 25 and the procedure with no problem.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
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    I am in agreement with Debra.
    Lisa Bledsoe, CPC, CPMA

  4. #4
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    Yes, the patients are scheduled to come in for the service. If the Dr. is spending more time than usual on the service wouldn't it be more appropriate to put a 22 mdifier on the service. I guess I don't follow why you would put a 25 modifier on the e/m??? If the e/m isn't a seperate service how could the 25 mod. be added? Thanks for the clarification.

  5. #5
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    Ok so they are scheduled to come in for the procedure and for some reason the procedure is more involved? then yes a 22 on the procedure code, but not because he spent time talking to or examining the pt.

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
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    Correct, if the procedure for some reason took longer then adding the 22 mod. would be ok.

    But my question was with the 25 mod. comment on the e/m. If they are coming if for a scheduled lesion removal how could you put a mod on the e/m? It's not seperate and distinct from the service. OR ..... Should the e/m not even be billed?

  7. #7
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    Quote Originally Posted by jhack View Post
    Correct, if the procedure for some reason took longer then adding the 22 mod. would be ok.

    But my question was with the 25 mod. comment on the e/m. If they are coming if for a scheduled lesion removal how could you put a mod on the e/m? It's not seperate and distinct from the service. OR ..... Should the e/m not even be billed?
    If scheduled for the procedure and no other problems addressed to meet the criteria for a separate E/M; then NO you should not code and E/M with mod -25.
    Lisa Bledsoe, CPC, CPMA

  8. #8
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    Thanks, that sums it all up. I appreciate all of the feedback.

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