Dermatology Coding Alert

Question: A 12-year-old male presents to our dermatologist with complaint of a bump on his foot. The patient reports that he has had the lesion for six months. He has pain when walking and playing sports.

The patient tells the dermatologist that the lesion feels better after the patient soaks in the bath tub. The dermatologist documents that the wart is 2 cm in diameter and depth, has no edema, and there is no redness or infection. The dermatologist recommends removing the benign lesion with liquid oxygen (LO2).
Our dermatologist applies LO2 to remove the lesion and instructs the patient on postsurgery care. How should we report this case?


Michigan Subscriber

Answer: Because the dermatologist performed a separate history, examination and medical decision-making, you should code for an E/M service. Therefore, based on the information above, you should code chart two's notes as 99212 (Office or other outpatient visit for the evaluation and management of an established patient) with modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) in addition to 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion]).

Tip: Despite rumors, you don't have to have two diagnoses to bill an E/M in addition to wart removal.

Example: In the above chart note describing the 12-year-old boy, you would report the service, even though you would use the same diagnosis for both the procedure and the E/M. For a plantar wart, you would link both 99212-25 and 17000 to 078.19 (Other specified viral warts).

Better method: Look for two of three elements. If documentation shows a full history, a procedure-related exam, and medical decision-making separate from the wart removal, you should report the E/M.

The separate medical decision may involve diagnosing the wart and deciding to remove it. When the E/M service can stand alone, you should use modifier -25.

Red flag: Make sure you attach the modifier to the service code (such as 99212), not to the procedure code (17000). Though your documentation supports 99212-25, this may not necessarily mean you'll receive reimbursement on the E/M. Payment depends on the insurer.

Extra: Include supporting information, such as CPT guidelines and the data from the National Correct Coding Initiative (NCCI). In a cover letter to the insurance company representative, explain that per CPT and NCCI, the insurer shouldn't include the E/M with the procedure.