# Would you bill the E&M? If yes, why?



## sjsantjer (Jan 12, 2012)

Would you bill the E&M? If yes, why? Thank you for your help!

Old patient been over 10 years since last visit. 

CC:  
1. Check mole.  Back, raising, irregular, present years. Pt Concerned, hard for pt to see it. 
2. Check R Hand. Rough area, present for months. No Rx yet.

Current meds…
KNA 
HX skin Cancer: No
ROS: 14 reviewed with pertinent answers listed.

Exam:  Pt is well developed, well nourished, oriented x 3, not acute distress, affect appropriate.  Back, inflamed Red keratotic papule 8mm.  Rt Ext, one red keratotic papule.

MDM:  
1. Inflamed SK/Other back
Bx x1  etc.…. 
Bx report came back Seborrheic keratosis showing irritation, inflammation.

2. Actinic Keratosis
LN2 x1 etc.…

Dr would like to bill:
99202-25
11100
17000


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## RonMcK3 (Jan 12, 2012)

Please note you'll likely get more and faster answers when you ask your E/M qeustion in the E/M forum.


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## BABS37 (Jan 12, 2012)

A new patient is one who hasn't received services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. Here's what I would do- 

Since the patient didn't come in for a planned procedure, I would bill the 99202 with 11100-59 and 17000.


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## syllingk (Jan 12, 2012)

I would 99202-25, 11100, 17000-59. For the same reason. The procedure wasn't planned.


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## mitchellde (Jan 12, 2012)

I would not bill an E&M because even though the procedure was not planned the assessment is not significant meaning it is not any more of an assement than what is needed to perform the procedures.  The documentation must be thereor it cannot be billed.


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## ollielooya (Jan 12, 2012)

This thread and resultant diverse replies are one of the reaasons I find E/M coding so challenging, maddening and compelling  It's also the reason why I'm utilizing the study guide in order one day to take the CEMC test.   Admittedly, I'm somewhat confounded by the last answer.  No EM at all for this new patient visit?  Please elaborate a little more as I'm having a little difficulty understanding the thought process here.   ---Suzanne E. Byrum CPC


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## mitchellde (Jan 12, 2012)

Just because this is a new patient does not automatically mean you get a new patient visit level.  The documentation must support the visit level.  Every procedure has as an inherent part of the procedure an assessment necessary to perform the procedure and to bill an additional assessment it must over above and beyond (significant and separately identifiable) what is needed for the procedure.  In otherwords the provider will not be able to perform the procedure with a blindfold on!  The documentation provided in this case is indicating an assessment only for what is required for the procedure and nothing significant to warrant a separate E&M.
I hope this is what you are wanting.


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## ollielooya (Jan 12, 2012)

Debra, indulge me, please, as I value your input as a veteran board member....Therefore, as the question was first submitted with the documentation presented and based upon this 'inherent part of the procedure' (this is a grey area, indeed), it still is insufficient to warrant an EM code assignment?  Am I understanding you correctly?   Guess, I really do need these EM studies because right now I'm second guessing myself all over the place.  Perhaps the question should be asked "at what point is the inherent part of the threshold reached?" based on the documentation submitted.  Can this be found in writing anywhere?  I'd really, really love to have that "inherent part" explained.
---Suzanne E. Byrum CPC


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## kathy a (Jan 26, 2012)

Yes you can bill for a new patient visit! Looking at the Medicare scorecard-
HPI:Location-Back, Timing-Years,Severity-Raising, Associated Signs and Symptoms-Irregular
ROSer note 14 reviewed with pertinent answers listed.
PFSH:None 
On the History part of the exam-Exp Problem Focused

EXAM: Constitutional, Skin, Psych-no acute distress.
This also would be an EPF

MDM:New problem to examiner-4, INdependent visualization of image-2 as well as review and order lab( biopsy ) =4,Biopsy is undiagnosed new problem with uncertain prognosis+ Moderate Complexity

On a new patient-one who has not been seen face to face in three years-youu would have EPF, EPF, Moderate= # 99202.  Kathy Albert,CPC


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## kathy a (Jan 26, 2012)

And actually you do have a past social history on the patient-who states about her not having any cancer.


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## mitchellde (Jan 26, 2012)

truely the assement is not SIGNIFICANT, it is not beyond what is necessary for the procedure there would need to be more assessment such as a description of a full body scan, the provider must know the answers to pertinent history question as well exam of the affect area to know what kind and how deep of an excision is needed, you cannot separate out the necessary elements of the eval from this procedure to be left with anything significant for billing.  Just because the patient is a new patient does not automatically indicate that a visit level can be charged.  I understand what every one is saying but honestly without the black and white dictation we cannot give credit for anything else.


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## classicblue21 (Jan 26, 2012)

*E&m-25*

​


mitchellde said:


> Just because this is a new patient does not automatically mean you get a new patient visit level.  The documentation must support the visit level.  Every procedure has as an inherent part of the procedure an assessment necessary to perform the procedure and to bill an additional assessment it must over above and beyond (significant and separately identifiable) what is needed for the procedure.  In otherwords the provider will not be able to perform the procedure with a blindfold on!  The documentation provided in this case is indicating an assessment only for what is required for the procedure and nothing significant to warrant a separate E&M.
> I hope this is what you are wanting.



I just posted my senario, my son went in to the dr's office because he had wax in his ear, the nurse wrote the reason for the visit, the doctor looked in both ears and irrigated the left ear, and cerum removed. they billed an 99213-25 The only documentation was 2 lines written by the doctor about what she did as stated above. When I asked to speak to someone in billing, they said well the nurse stated there was a d/c of blood in the ear. wouldn't the nurses notes be an inherent part of the visit to perform the procedure. I know I am rusty, but the reason for the visit was cerum in the ear, nothing else. Thanks


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## MnTwins29 (Jan 27, 2012)

*They billed for removal?????*



classicblue21 said:


> ​
> I just posted my senario, my son went in to the dr's office because he had wax in his ear, the nurse wrote the reason for the visit, the doctor looked in both ears and irrigated the left ear, and cerum removed. they billed an 99213-25 The only documentation was 2 lines written by the doctor about what she did as stated above. When I asked to speak to someone in billing, they said well the nurse stated there was a d/c of blood in the ear. wouldn't the nurses notes be an inherent part of the visit to perform the procedure. I know I am rusty, but the reason for the visit was cerum in the ear, nothing else. Thanks



As in 69210?   Egad, if I had a dime every time I saw this code used improperly, you wouldn't see me here - I would be hiding away in the Cayman Islands!


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## cheermom68 (Jan 27, 2012)

*e/m*

I totally agree with Debra.  Unless the physician did something *over and above what is normally needed to assess for and perform the procedure, according to CMS, there is No billable E&M.  25 modifiers with these type of procedures are on the OIG list this year.  
LeeAnn*


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## FTessaBartels (Jan 27, 2012)

*NOT a social history*



kathy a said:


> And actually you do have a past social history on the patient-who states about her not having any cancer.



This statement is NOT social history. Social history would refer to marital status, tobacco or alcohol use, safe sex practices ... for younger patients level of schooling or whether they attend day care, etc. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## GaPeach77 (Feb 27, 2012)

sjsantjer said:


> Would you bill the E&M? If yes, why? Thank you for your help!
> 
> Old patient been over 10 years since last visit.
> 
> ...



I used the CMS scorecard as well and yes an E/M can be billed based on the documentation. Its a problem focused exam. I came up with 99202 as well.


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## mitchellde (Feb 27, 2012)

simonewill7 said:


> I used the CMS scorecard as well and yes an E/M can be billed based on the documentation. Its a problem focused exam. I came up with 99202 as well.



I agree the E&M meets the criteria for the 99203 HOWEVER... It does not meet the criteria to bill it in addition to the procedure. There is nothing in the exam that is significant to the procedure, only exactly what is needed for the procedure.


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