Pediatric Coding Alert

Question: Can I charge for a 99213 and a 17250 on the same day at the same visit if I add modifier 25? The procedure was not scheduled prior to the office visit. 

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Answer: If your physicians documentation supports a significant, separately identifiable E/M service, you can report 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) and 17250 (Chemical cauterization of granulation tissue [proud flesh, sinus or fistula]). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to indicate that there was a separate E/M service.

Caution: Do not add a 25 modifier just because the procedure was not scheduled prior to the visit. If the E/M service your physician performed is only the minor E/M associated with the procedure, you cannot add modifier 25.

The documentation and medical necessity must demonstrate that the E/M was a significantly, separately identifiable E/M. The fact that the procedure was not scheduled helps, but is not an automatic indication to append modifier 25.  Physicians should ask themselves, “Did I really have to evaluate the patient to determine the need for this procedure?” If the answer is yes, then don’t hesitate to bill for the E/M code. 

Good practice: Having the procedure documented on a procedure note, separate from the E/M, and then having E/M documentation that shows a full workup that led to the decision to do the procedure helps support a separate code.

If the procedure is diagnostic in nature, the findings of the procedure cannot be in the exam section of the E/M. You cannot count these elements twice, once for the exam and once for the procedure.