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Debriment code with E/M level

  1. Unhappy Debriment code with E/M level
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    The following documentation was billed and denied when we billed:
    99212 & 11721
    Should I attach modifier 25 to the E/M code?

    Thank you.

    76 y.o. female NIDDM with CC painful elongated thickened nails. Nails are painful when she Is walking in her Shoes or sneakers.


    PE: + elongated thickened painful dystrophic nails X 10 with subungual debris.
    - interdigital maceration, - ulcers, - fissures, - SOI
    Skin is dry and scaling plantarly
    DP/PT 2/4 B/L CR 1 sec X 10 TG WNL B/L - pedal edema


    ASS: Onychomycosis X 10, Xerosis


    TX: Debridement of mycotic nails X 10.
    Rx Lac Hydrin 12 % Lotion 8 oz bid 3 refills


    F/u 3 months

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
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    Quote Originally Posted by tvmedical@earthlink.net View Post
    The following documentation was billed and denied when we billed:
    99212 & 11721
    Should I attach modifier 25 to the E/M code?

    Thank you.

    76 y.o. female NIDDM with CC painful elongated thickened nails. Nails are painful when she Is walking in her Shoes or sneakers.


    PE: + elongated thickened painful dystrophic nails X 10 with subungual debris.
    - interdigital maceration, - ulcers, - fissures, - SOI
    Skin is dry and scaling plantarly
    DP/PT 2/4 B/L CR 1 sec X 10 TG WNL B/L - pedal edema


    ASS: Onychomycosis X 10, Xerosis


    TX: Debridement of mycotic nails X 10.
    Rx Lac Hydrin 12 % Lotion 8 oz bid 3 refills


    F/u 3 months
    You would need to use modifier 25 to show that the procedure done after the evaluation of the problem.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Location
    Fargo, North Dakota 70102
    Posts
    18
    Default
    Since the E/M was all focused on the nails and then he determined that they needed debridement, the E/M level is included in the procedure code. You would only be able to code an E/M in addition to the debridement if the E/M was pertaining to a problem other than the nails (e.g. cough, high blood pressure, etc.) I am in compliance so I take the conservative road.

    Rhonda

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