# Modifier 25 with 11100, new patient, one diagnosis



## JesseL (Oct 24, 2013)

In the case below can I bill it this way:
99202-25 dx 238.2
11100 dx 238.2
11101 dx 238.2

I'm getting a lot of conflicting information on these forums that you can or can't bill e/m with minor procedure even if it's a new patient.

Chief Complaint and/or History of Present Illness
Complaint(s):
1. Multiple growths and/or leisons on forehead, left cheek, left jaw and right cheek
Duration: few months
Severity: worsening
Quality: dull
Timing: constant

Past History
Past Medical History (PMH):
• Admits Hypertension
• Denies immunosuppressed, pacemaker, antibiotics prior to dentistry, skin cancer, hiv/aids, pregnant, nursing a baby,
hyperthyroidism, hypothyroidism, lupus, polycystic ovarian syndrome, blood clot, cancer, kidney disease, asthma,
hayfever, artificial joints or heart valves, diabetes, glaucoma and hepatitis
• Comments: Cholesterol
Family:
• Denies family history of acne, eczema, cancer, lupus, malignant melanoma, non melanoma skin cancer
and psoriasis
Review of Systems (ROS):
• Admits Integumentary System (skin problems)
• Denies bleeding problems, breathing difficulties, respiratory symptoms, cardiovascular problems or chest
symptoms, nausea,fever,diarrhea, endocrine related symptoms, eye or vision problems, gi symptoms,
joint or musculoskeletal symptoms, neurological symptoms or problems, psychiatric or emotional
difficulties, genital urinary symptoms, ear, nose, mouth or throat symptoms and integumentary
Social:
• Denies: Alcohol Use, Illicit Drug Use, Profession, Smoking (Never smoked), Tobacco / Smoking Cessation
Intervention, Tobacco Use
Surgical History
• Denies cancer surgery, gi surgery, heart surgery, joint replacement and plates/rods/screws/stents
Allergy:
• Patient denies allergy to medication
Medications
• HBP medication
• Cholesterol medication
Physical Exam, Diagnosis, Medical Decision Making and Plan of Care
Constitutional, Neurological and Psychiatric Notes:
• Patient is a 58 year old female who appears to be well developed and well nourished with good attention
to hygiene. Psychiatric Note: The patient appears to be oriented by time, place and person.
Skin Type:
• Patient has skin type IV (Beige with a Brown Tint).
Exam Type:
• Above the Waist Except Breast exam was performed on scalp (including hair), head (including face),
neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, and back.
Exam:
1. Neoplasm of uncertain behavior, skin
Brown, hyperkeratotic, irritated, itching, papule (s), scaly located on forehead, left cheek, left jaw and right
cheek
Medical Decision Making: Neoplasm of uncertain behavior, skin , observe
POC: Recommendation is Bacitracin and dressing applied in office., Explained biopsy procedure to
patient. Discussed possibility of the need for further treatment based on pathology findings. Consent
obtained (see chart). Biopsy performed (see procedure note).
Biopsies:
1. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, Irritated, Itching, Papule (s) and Scaly located on Left Cheek, See Biopsy note for
details.
2. Neoplasm of uncertain behavior, skin
Brown, Hyperkeratotic, inflamed brown stuck on papules and plaques, Irritated, Itching, Papule (s) and
Scaly located on Left Jaw, See Biopsy note for details.
POC: Recommendation / comment: explained biopsy procedure to patient. discussed possibility of the
need for further treatment based on pathology findings. consent obtained (see chart). biopsy performed
(see procedure note)., bacitracin and dressing applied in office.


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## mitchellde (Oct 24, 2013)

You can have an E&M with the 25 modifier you just have to have the documentation to support this, However you cannot use the 238.2 dx code unless you have a path report.  The 238 codes require a histologic confirmation of the fact that the patient has a neoplasm that cannot be classified as either malignant or benign.


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## JesseL (Oct 24, 2013)

Does the documentation I have here support the use of modifier 25?  So I'm suppose to code the path results?  How would I code it if the Path came back as lipoma for example?

99202-25 238.2
11100 dx lipoma
11101 dx lipoma

Like that?


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## JesseL (Oct 28, 2013)

Anyone?


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## mitchellde (Oct 28, 2013)

sorry the 99202 must have a dx code other than the 238.9 as well unless you have a path report.   
It would appear that you have sufficient documentation to support the 99202.


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## mitchellde (Oct 28, 2013)

I agree I think you misunderstood me, I was referring to the use of the 238.2 dx code without the benefit of a path report.  Not that she needed a different code for the ov from what was used for the procedures.


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## JesseL (Oct 29, 2013)

so does this mean I can only bill for the 11100 & 11101 with the path diagnosis?


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## mitchellde (Oct 30, 2013)

No you can bill all either with the symptom code or you must hold the entire claim and wait for a path report.  the 238.2 code is a pathologically rendered diagnosis.  It is not a symptom nor can it be used to reflect provider uncertainty.  The provider has described skin disorders so that is what you may code or you may wait for path.  They are not lipomas either.  under the assessment I am thinking the provider chose the dx from the EHR which is not always the same as what the provider would have stated in their own words.
As stated though you can use the same dx code for all services on the claim.


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## JesseL (Oct 31, 2013)

I'm sorry but I'm still confused because OTC_coder is saying I can't bill the e/m because documentation doesn't support it and Mitchellede is saying I can... which is it???

I only used Lipoma as an example.  So I'm suppose to bill by the symtoms like 782.0 "skin sensation disturbance"?

11100 - 782.0 not with the lipoma code if let say the result was lipoma?

There's so much conflicting information in regards to billing minor procedure with e/m with same dx.

Very frustrating.


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## mitchellde (Oct 31, 2013)

to bill a procedure that was not previously planned with an E&M, the E&M must be significant and separately identifiable.  To perform the procedure the provider must examine the area in question so that examination is inclusive to the procedure.  The part of the note that states "Exam Type:
• Above the Waist Except Breast exam was performed on scalp (including hair), head (including face),
neck, axilla, right upper extremity, left upper extremity, hands, chest, abdomen, and back." , makes this a significant note as he went beyond the exam of the areas that were biopsied and it was medically necessary that he do so.
As far as the dx goes, you can use the symptoms and send it off OR you can wait for the path and bill with the path.  if you do not wait for the path then all procedures and the E&M will have the same dx code, if you wait for the path and they all have the same path then all will have the same code, if they have different results, say one is basal cell and one is melanoma, the you will list both dx codes and link the basal to one procedure and the melanoma to another and link them both to the E&M.  You just cannot use a path dx without a path report.


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## JesseL (Oct 31, 2013)

Thanks for responding mitchelled.

So the path came back as viral wart for both.

So i would code it this way?

99202-25 dx disturbance skin sensation or am i suppose to use wart here to?
11100 dx viral wart
11101 dx viral wart


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## mitchellde (Oct 31, 2013)

you use the path dx for all codes then the E&M and the procedures, do not use a symptom once you know the definitive dx.


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## JesseL (Nov 2, 2013)

mitchellde said:


> you use the path dx for all codes then the E&M and the procedures, do not use a symptom once you know the definitive dx.



Thank you for your help


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