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E/M verus Office Procedure - Pt came in for warty growth cells

  1. #1
    Question E/M verus Office Procedure - Pt came in for warty growth cells
    Medical Coding Books
    Pt came in for warty growth cells. Dr did destruction of lesion.

    His diag was 238.2 & 702.11 procedure code 17000, but he also is charging a office visit with a modifier. 99213-25 Would you justify this, because I do not see what he would be linking to the office visit. The diag. that he used are both linked to the procedure. If he should not have used the office visit with modifier is there any where's in the ICD-9 coding guidelines that would explain this to him.

  2. #2
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    probably nothing that will explain it to him to his satisfaction! but, in our CPT books, under Appendix A it's VERY clear when we should use a .25 on the office visit. From the info you've given, it doesn't appear that he's done anything beyond the usual for the procedure that was provided.
    Another thing, are you sure you want to use 17000 and not 17110?
    Donna, CPC, CPC-H

  3. Default
    I'm no guru but couldn't she append the E/M code with 57 if he visited w/ the patient and then decided to do the surgery?

  4. #4
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    Mod -57 is not appropriate for CPT codes of 0-10 global days.

    I'm curious about the documentation and the use of 238.2 and 702.11. Can we get more details of the note?

    Lisa

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    Was this a planned procedure? If so, then the E/M would not be justified however if not and the doctor did an eval of the patient and documentation supports the 99213 level, then it would be appropriate to put the 25 modifier on the office visit and bill for the procedure performed as well. It does not have to be a different diagnosis.

  6. Default modifiier -25 - check out NCCI policy manual
    Your best answer to this will be found in the NCCI policy manual. - you can look in the E/M chapter and the integumentary chapters. You'll find sound advice and an authoratative reference for your physicians and staff. Procedures, even the 10-day global procedures, carry "routine pre-operative work up". So even if you do meet history, exam and medical decision making, and CPT says use modifier -25, you still need to be very careful before billing out both. Here is the link to the NCCI policy manual. Open it up and scroll down to the bottom and open the "NCCI policy manual for Part B Medicare Carriers" Check chapters one, three and eleven. This is a very often "overlooked" reference to most coders and practices.

    Good luck!

    -http://www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp#TopOfPage


    Linda Eickmann

  7. #7
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    I have to respectfully disagree with you mbort - though the docs wish (and want) and often we feel we should charge an E/M .....
    it's a given that the doc has to examine/evaluate the patient BEFORE performing the procedure. it has to be "beyond" the expected, normal or "routine" exam in order to be able to bill out an E/M. And, of course - documentation has to support the level chosen.
    but now I'm going to go check out the website lindaeickmann gave and see what else I can learn!
    Donna, CPC, CPC-H

  8. #8
    Default e/m verus office procedure
    Quote Originally Posted by Lisa Curtis View Post
    Mod -57 is not appropriate for CPT codes of 0-10 global days.

    I'm curious about the documentation and the use of 238.2 and 702.11. Can we get more details of the note?

    Lisa
    Lisa

    This is another case where the patient came in for warts (078.10) dr. removed the warts 17000 and also gave a gardisil injection (v05.8) he coded the superbill as 99213-25, 17000, 90471, 90649 diag was 078.10, v05.8

    99213-25
    17000 - 078.10
    90471 - v05.8
    90649 - v05.8

    how would you justify using the e/m with modifier? what would you link it to

    the documentation for 238 states that it is neoplasm of uncertain behavior of other and unspecified sites and tissues. 238.2 is for SKIN, 702 states: Other dematoses 702.11 is inflamed seborrheic keratosis

    the physician coded as:

    99213 - 25
    17000
    the two diag's were 238.2 & 702.11 and both of those can be linked to the procedure 17000, so I wasn't sure if he should have used the e/m with modifier.

    thanks for you comments

  9. #9
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    Quote Originally Posted by kimb View Post
    Lisa

    This is another case where the patient came in for warts (078.10) dr. removed the warts 17000 and also gave a gardisil injection (v05.8) he coded the superbill as 99213-25, 17000, 90471, 90649 diag was 078.10, v05.8

    99213-25
    17000 - 078.10
    90471 - v05.8
    90649 - v05.8

    how would you justify using the e/m with modifier? what would you link it to

    the documentation for 238 states that it is neoplasm of uncertain behavior of other and unspecified sites and tissues. 238.2 is for SKIN, 702 states: Other dematoses 702.11 is inflamed seborrheic keratosis

    the physician coded as:

    99213 - 25
    17000
    the two diag's were 238.2 & 702.11 and both of those can be linked to the procedure 17000, so I wasn't sure if he should have used the e/m with modifier.

    thanks for you comments
    Well, here's my two-cents:

    Regarding the patient who came in for warts and gardisil, I would use 17110/078.10; 90649 and 90471/V04.89. No E/M if the patient was scheduled specifically for these reasons.

    Regarding the first scenario - 17000/702.11 seems ok. I don't know that 238.2 is appropriate if he didn't biopsy. There are two answers in this thread regarding coding the e/m...personally, I lean toward Donna's answer because there is an e/m component inherent to all procedure codes. You have to determine at what point the separately identifiable e/m occurred. What adds to this confusion is that there does not need to be a different diagnosis when using -25. If there isn't enough documentation to support the e/m separate from the procedure, I would caution against coding it. And again, if the patient was specifically scheduled for the lesion destruction you shouldn't code an e/m. Hope that helps...some...

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