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Provider billing E/M with procedure

  1. Default Provider billing E/M with procedure
    Medical Coding Books
    Provider chose a 99213 with procedure. I feel this visit would only support a 99212 with 17110 our other coder feels that we shouldn't even bill the 99212 only the procedure code. Whats you thought??

    Visit Type: Acute Visit
    Primary Provider:

    History of Present Illness:

    Has had a prominent wart on his left thumb pad for more than a year. Gets in his/her way. Wants it frozen off.

    Vitals entered by:
    Entered weight: 157 lb.
    Calculated Weight: 157 lb.

    Blood Pressure: 110/48
    Position: Sitting Site: L Arm Cuff: Regular

    Temperature: 97.6 deg F.
    Temp Site: tympanic
    Pulse rate: 60
    Pulse rhythm: regular
    Respirations: 18

    Past Medical History:
    Reviewed history from 01/02/2007 and no changes required:
    previous purulent rhinorrhea

    Family History:
    Reviewed history and no changes required:

    Social History:
    Reviewed history from 01/02/2007 and no changes required:
    lives with parent

    Risk Factors:

    Physical Exam

    Well appearing child, appropriate for age,no acute distress
    Clear to ausc, no crackles, rhonchi or wheezing, no grunting, flaring or retractions
    RRR without murmur
    Left thumb pad wart.
    alert and cooperative

    Test Management:

    New Orders:
    1) Ofc Vst, Est Level III (CPT-99213)
    2) Destruction 1st Lesion (CPT-17000)

    Impression & Recommendations:

    Problem # 1: WARTS, VIRAL (ICD-078.10)
    Treated with liquid nitrogen in freeze/thaw fashion x 3--tolerated well. Instructed in care. Recheck if needed.
    Ofc Vst, Est Level III (CPT-99213)
    Destruction 1st Lesion (CPT-17000)

  2. #2
    Columbia, MO
    I do not see an office visit as nothing is documented that is over and above the procedure, however for wart destruction you need to use 17110.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Code 17110 has a 10 day global which means the day of the procedure and the 10 days following. I would only bill an office visit with a 25 if they came in with another problem totally separate than the wart. In a CMS conference I attended last month, it was stated more than few times that Medicare is monitoring the usage of modifier 25. So if a patient comes in and we do an I&D and they have no other problem going on, that is the only thing we code for. Be careful with modifier 25. Medicare is watching.

  4. #4
    Default E&M with mod.25
    It is true that Medicare is wathcing the usage of mod.25 and the rule is if an E&M service is performed on the same day as a procedure, it is not paid unless a significantly seperate identifiable service is rendered. So, it appears that the only service the pt. was coming in for was to have the wart removed, so I would code only the wart, unless you feel you can justify the reason for the E&M also.

    Aslo, keep in mind even though the rule for the 25 mod. has to be seperate and identifiable you do not have to have a different dx. in order to use the modifier, meaning if a procedure was done the dx. for the procedure does not have to be differ from the E&M.

    Hope this helps.

  5. Default
    I could see billing an office visit with a 25 modifier and the procedure code as long as the patient had not presented on an earlier date and had this evaluated for treatment. The patient may have presented to the office assuming this was going to be removed, however, the physician has to evaluate and make the decision to perform the procedure. Because it's not major surgery, you wouldn't use the 57 modifier, but a 25 modifier is appropriate.

  6. Default
    1st I think a wart removal is 17110, they are not pree malignant as the 17000 states.
    And if they present for removal of wart with no other complaints then you should not bill the ov.

  7. #7
    I agree with Clark100 and here's why.
    Two scenarios (hope this helps)
    Scenario 1: Pt: Hey Doc I got a wart. Doc: yep you do, bye....Charge = OV
    Scenario 2: Pt: Hey Doc I got a wart. Doc: Let me see that...How long have you had this? Do you have any others? Does it bother you? Have you ever had any before? Let me remove this for you...Charge = OV + Procedure.

    The questioning pertinent to the wart "is" the seperate identifiable service.
    Also I believe, and someone correct me if I am wrong, that E/M is "not" bundled into procedures with 10 day globals.

  8. Default
    I agree that an office visit is applicable if this is indeed the first time that the wart has been examined. I get 99213 from the documentation assuming this is an established patient.

  9. #9
    Milwaukee WI
    Default E/M included in procedure
    I agree with Debra Mitchell on this case. The patient presented to have the wart removed. The basic evaluation done is a component of the procedure and is NOT separately reportable in this case.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  10. Smile
    I also say 17110 only. I do not see a significant, separately identifiable E/M service.

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