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Thread: Modifier 25 - Patient sees dermatologist for skin

  1. #1

    Default Modifier 25 - Patient sees dermatologist for skin

    AAPC: Back to School
    Please let me know your thoughts on the following.

    Patient sees dermatologist for skin lesion and the decision is made to remove lesion either by excision or cryo. The physician is doing what he calls a waist up exam looking for other lesions. Documentation reflects only "waist up exam ok” and description of cryo/excision procedure.

    Now for my question. Would it be appropriate for that doctor to bill a 99212-25 for that waist up exam?

    Thank you,
    Linda CPC
    Last edited by ank3t; 10-20-2016 at 05:29 AM.

  2. #2


    I'll offer my two cents. If the dermatologist is examining the patient for similar lesions as he removed in his procedure would that be considered separately identifiable and distinct? He did perform a "piece" of an exam on a different part of the body, so I would consider giving him credit for it.

  3. #3


    Yes as you said he did do a piece of an exam. I have a hard time with the medical necessity of that piece. Would it be considered screening or due to the fact that the patient has this one lesion on back would that then give him the necessity to exam other skin areas?
    Thanks for your reply,

  4. #4


    If The Doctor Did Remove Lesion Use A Modifier 25.. Then He Would Get Paid For The Office Visit And The Lesion Removal..

  5. #5


    I suppose it could depend upon what the patient's history and age is and if the physician felt it necessary to check for potential abnormalities. You asked a challenging question. Medical necessity, as you have indicated, is usually a gray area.

  6. #6
    Join Date
    Apr 2007


    Does the removal of the lesion CPT code carry a 10-day global? This determines the use of the -25 versus a -57.

  7. #7
    Join Date
    Apr 2007

    Default Waist Up Exam

    If the doctor only documents "waist up exam" without listing each area examined, NO I would not code an office visit on a new patient because you will not have the required 3/3. If established, must have 2/3.

    See for new vs established patient for modifier 25.http://www.medicarenhic.com/cal_prov...ier25_1006.htm



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