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Thread: Compliance issue??

  1. #1
    Join Date
    Apr 2007

    Default Compliance issue??

    AAPC: Back to School
    Patient presents for debridement & dressing of burn.

    Physician wants to charge a 99212, however there is a code for debridement & dressing that applies- 16020. I added 16020 and did not charge an E&M. Now the physician has come back to me stating he does not want to charge the procedure code, only an OV because the patient is self pay.

    I've been told that if I can pull info out to meet a 99212 then to charge it and not the procedure. My question is compliace wise is this okay to do? I feel uneasy charging an E&M when I know there is a procedure that was performed. I feel like if the physician doesn't want to charge the patient for the procedure (because the pt is self pay) then he should just no charge the visit all together.
    Does anyone know the exact rule on charging an E&M rather than a procedure when a procedure is performed? It seems fraudulant to me.....

  2. #2


    I would use the 99212 with 16020 and append modifier -25 for significant and separately identifiable E/M by the same physician on the same day of the procedure and other service as long as the E/M did not prompt the decision for the surgery.

  3. #3
    Join Date
    Apr 2007


    When the patient initially came in I did charge 99212 -25, 16020. The patient returned 2 days later for debridement & dressing change and I only charged 16020 as a separate E&M was not provided.

    They would like me to charge 99212 without 16020 on the second visit because 99212 is cheaper. I don't agree with this but I'm told by higher ups that it is okay "because we are not billing to insurance" since the patient is self-pay.

    The note is still in the SOAP format like an E&M would be documented, however the only thing in the exam is documentation of debidement and dressing change. MDM states return in so many days. History states "Patient presents for debridement". Since a procedure was performed it just doesn't seem right to bill an E&M and not the procedure.

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Procedure only

    The patient presented for the procedure, and that is all that should be coded.

    If the physician wants to accept a reduced payment based on the patient's financial hardship, then you should have a well-documented - and followed across-the-board - policy in your office to handle such situations.

    What if the "procedure" had been fracture care rather than burn debridement?

    You cannot treat one patient differently from another patient.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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