Podiatry Coding & Billing Alert

Question: Our podiatrist saw an established patient for an ingrown toenail. During the exam, the podiatrist notices that the patient also has an infected foot wound and administers an intravenous antibiotic. In this scenario, in addition to the appropriate code for the toenail excision, can you report a separate and significant evaluation and management (E/M) service for the unrelated infected foot wound using modifier 25 along with the appropriate E/M code?

Wyoming Subscriber

Answer: Yes, you can use 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) in this scenario. This modifier applies when a provider or other qualified healthcare professional performs an E/M service on the same day as another service to the same patient by the same physician, regardless of whether a patient is new or established.

In this situation, the provider treats a problem (the foot infection) that is separate from the other problem that originally caused the patient to present for the encounter (the ingrown toenail excision). As the problem is separate and significant, you can bill for both the procedure and the appropriate E/M code from 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …) appending modifier 25 to the E/M code. In this scenario, you would also bill for 96379 (Unlisted therapeutic, prophylactic, or diagnostic intravenous or intra-arterial injection or infusion) for the treatment of the infection in addition to the office visit, and 11750 (Excision of nail and nail matrix, partial or complete [eg, ingrown or deformed nail], for permanent removal) for the toenail removal.

Pro coding tip: There are a few basic same-day situations to look for that may justify the use of modifier 25 on an E/M code, according to Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal at Lehrman Consulting LLC, in Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?” Those situations include:

• One problem gets E/M, and another problem gets a procedure
• New patient (most of the time, but not always)
• Established patient with a new problem
• Established patient with a change in an existing problem

For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” explains Lehrman. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today…,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the _________ was significant and separately identifiable from the procedure of ____________,’” he says.