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Thread: Initial visit using modifier 25 with minor surgery

  1. #1

    Default Initial visit using modifier 25 with minor surgery

    AAPC: Back to School
    I am going back and forth with this example to decide is modifier 25 is appropriate. Podiatrist is requested (consult) to see a new patient in the nursing home for mycotic nails. The podiatrist performs a 11721 (debridement of 6 or more nails) on patient. The podiatrist only bills out the initial 99304 visit. I know that an E&M code is part of the pre&post surgery code. I am trying to figue out if a modifier 25 (seprate above and beyond warrants this example)? I ask myself "did the podiatrist know that they were going to perform debridement automatically", I don't know and can't assume a yes or no answer to this. I have read the Medicare guidelines that it doesn't matter if a patient is new or established regarding the pre & postoperative care associated with the procedure or service that was performed. Any advise or opinions would be greatly appreciated to ease this confusion of a gray area I am having.

  2. #2


    Here's how I look at it and again this is only my opinion. Since a consult was already requested of the podiatrist for the specific reason of mycotic nails and he ended up doing some debriding, I don't think an E/M should have been billed. Think about it this way..if a patient comes in for specifically having warts removed and has them removed, unless there was something separately wrong with them during the visit (for example the flu) then you cannot bill a separate E/M.

    Now if the doctor was called in for a general consult of the patient and ended up doing some nail debridement then you can bill the debridement and E/M since it's a separate issue.

    Hope this helps

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