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Modifier 25 usage in wound clinic

  1. Default Modifier 25 usage in wound clinic
    Medical Coding Books
    Is it appropriate to bill a facility E/M (99211) on every visit in a wound clinic regardless of a procedure being done or not?

    The clinic is a hospital outpatient department and is billing every patient 99211 and adds modifier 25 if a procedure is done (this is for the facility charges). The physician's charges are entered separately.

    My understanding is that this is not appropriate to do, as a matter of practice, on each and every visit unless the E/M is separately identifiable. But I am wondering if there may be some different rules where this is a facility charge.

    The clinic manager argues that we are charging for our nursing/facility resources for each visit that are not specifically related to the procedure (vitals, review of history etc.). My argument is that these are not separately identifiable and are considered included in the facility payment for the procedure.

    Established patient returns for wound debridement
    Facility charges: 99211-25, 11040
    Physician charges: 11040

  2. #2
    Central Indiana
    We have patients that come in for Unna boots and had previously been charging 99211-25 with the Unna boot code. I am in agreement with you that it is inappropriate to do so. Unless they have documentation of an additional problem at the time, the purpose of the visit is the wound care. You should not charge separately for vitals being taken.

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