Podiatry Coding & Billing Alert

Question: We have a podiatrist in our practice that insists on adding an office/outpatient evaluation and management (E/M) code for every patient that already has an established plan of care. The provider states that the patient’s care plan changes at every encounter, even if they are coming in for care of an ulcer they have had for years, as the wounds are always changing.

However, when I look at the documentation, I see nothing has changed since the last encounter, and no new problems are being addressed to justify the E/M. How do I communicate effectively to the provider that only the procedure can be billed in these circumstances?

AAPC Forum Participant

Answer: In order to legitimately bill an established patient E/M using 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) along with any procedure, you must 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 the E/M. As the descriptor language indicates, this the E/M must address a problem that is significant and separately identifiable from the problem the provider is addressing with the procedure at the encounter.

However, you say there is nothing in the notes to show that a separate or significant problem is being addressed at the encounter. So, if there is no diagnosis on the E/M that is different from the diagnosis listed to justify medical necessity for the procedure, you cannot bill for the E/M.

This is true of many encounters in podiatry, where patients are often seen for ongoing care of an existing complaint. Unless there is a new complaint, or a major modification to an existing care plan that takes a new complaint into account, you should only bill for the procedure. Any minor evaluation and management of an existing condition would be covered as a part of the service described by the appropriate procedure code.