# Examination Question



## Inquisitor (Feb 23, 2009)

If, on a new patient visit, the provider sees a patient for a laceration and documents the complete history, then under examination notes "Wound treatment/repair: 2.5 cm superficial oblique laceration of the dorsal aspect of the right distal phalanx of the thumb...wound appears clean, no visible foreign bodies, skin margins regular. Neurovascular exam intact, sensation distal to the wound intact, circulation intact, motor function intact.  On direct inspection there is no tendon involvement. After cleansing wound was anesthetized with 1% lidocaine locally. Wound scrubbed w/Hibiclens. Six 5-0 inturrupted simple ethilon skin sutures were placed. Sterile dressing applied and wound bandaged.  

Provider wishes to bill new patient visit w/mod -25and surgical repair.

Do you count examination elements noted within the wound treatment section or does there have to be a distinct separately documented examination?

Is there a definition somewhere denoting what is considered "inherent" to a procedure?


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## RebeccaWoodward* (Feb 23, 2009)

Minor Surgeries and Endoscopies Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

So...in a nut shell, a minor surgery includes an inherent E/M component. When trying to decide if an E/M service is separate and significantly identifiable, look for documentation that sets your E/M apart from your minor procedure. 

40.1 C

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf


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## FTessaBartels (Mar 5, 2009)

*New patient exempt from Mod 25*

Actually NEW patient visits are exempt for the mod -25. You don't need the modifier because there is an inherent understanding that a new patient requires some evaluation. 

As for your documentation ... I'd phrase it differently ... the procedure needs to be clearly and separately documented from the E/M. 

If your entire "exam" documentation is the procedure, then you don't have an E/M.

F Tessa Bartels, CPC, CEMC


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## Inquisitor (Mar 6, 2009)

Thanks again FTessaBartels!  Always helpful!


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## RebeccaWoodward* (Mar 12, 2009)

Tessa,

I will have to respectfully disagree with you on the use of modifier 25 on a new patient visit.  I've done a great deal of research on this and that was Medicare's mentality years ago.  Some Medicare contractors might follow this rule of thumb but I can tell you that our carrier will deny our E/M without this modifier. Unless you can show me differently (Not an individual contractor), *CMS* doesn't have this verbiage any longer.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

30.6.6


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