Primary Care Coding Alert

Often a patient comes in for a regular office visit, and the family physician (FP) discovers a dermatological problem such as a mole, wart or skin tag. Instead of asking the patient to return, the physician usually performs an excision, destruction or biopsy during the office visit. Receiving proper reimbursement for these common encounters involves billing the visit and the procedure separately.
 
"In most cases, when an E/M visit turns into a dermatology procedure, coders should bill for the office visit and procedure separately," says Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions, a physician reimbursement company in Lakewood, N.J. "And append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code."
 
For example, a 52-year-old woman presents to have her asthma checked. The FP discovers a skin lesion on her back, and the doctor performs a biopsy immediately. You can bill for the biopsy (11100, biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed [separate procedure]; single lesion) and the appropriate E/M visit in this case 99212 or 99213 (office or other outpatient visit for the evaluation and management of an established patient) with modifier -25 attached to the E/M code.
 
"The minor surgical procedure does not raise the level of the office visit because it is considered separate," Cobuzzi says.
 
"A lot of payers don't want to pay for the office visit separately for these types of visits,'' says Carol Sissom, CPC, senior consultant at Health Care Economics Inc., a coding and practice management firm in Indianapolis. "It's helpful to send the documentation for the office visit.''

Many of the dermatology removal codes are starred. Associated pre- and postoperative services are not included in starred codes. The surgery guidelines in CPT 2002 state that when a starred procedure is performed at the time of an initial or established patient visit involving significant identifiable services, "the appropriate visit is listed with the modifier -25 appended in addition to the starred procedure and its follow-up care."
 
For example, a 48-year-old man presents to have his blood pressure checked. While listening to the patient's lungs, the doctor sees a suspicious mole of 0.3 cm on his back and shaves it off. Code the appropriate E/M visit and append modifier -25. Also code for the mole removal with 11300* (shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs, lesion; diameter 0.5 cm or less).
 
But when a new patient comes in and a starred procedure is performed, different rules apply. For example, a new patient presents, and at the beginning of the visit the FP finds a skin lesion of 0.5 cm in diameter on the back of her neck. The physician removes it by shaving. Most of the visit is spent performing this procedure. Use 11305* (shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less) for the minor procedure and 99025 (initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) for the new patient visit.
 
"Reporting 99025 indicates that three components of a new patient E/M service were not provided, but that an abbreviated history was taken and the record was established for the new patient," says Kent Moore, manager of Health Care Financing and Delivery Systems at the American Academy of Family Physicians in Leawood, Kan. 

"The coder would bill for only the dermatological procedure and not the E/M if the physician did not document the E/M or if the patient came in for a scheduled dermatology procedure," Moore says. 
 
The greatest challenge in billing for E/M services and minor procedures is when the patient presents to have a skin lesion "looked at." The patient is not simply scheduling a checkup, nor is he or she coming in to have the lesion removed. "The key here is that minor procedures, such as lesion removal, have an inherent E/M associated with them," Cobuzzi says. "For example, if a patient comes in to discuss a mole, and the doctor performs a biopsy of the mole, the E/M portion is included in the biopsy. You can only code for the procedure." Under these circumstances, you can bill for a separate E/M with modifier -25 only if there is thorough documentation showing that the physician performed a totally separate procedure.

When the office visit and procedure are billed, two separate diagnosis codes are helpful but not required.  "However, it is more difficult to support the separate visit if you only use one," Cobuzzi says. "More and more private payers are not paying for a separate E/M visit when you only have one diagnosis code, even though correct coding says you don't have to if you use modifier -25."
 
For example, a patient presents to have his type-II diabetes checked, and the doctor notices a dark mole on the patient's arm and performs a biopsy. Link 250.xx (diabetes mellitus) to the office visit code with modifier -25 appended, and link 216.6 (benign neoplasm of skin, skin of upper limb, including shoulder) to 11100.
 
Don't use two different diagnoses when a patient comes in to have a skin lesion looked at. For example, a patient has a bad itch on his back. The doctor determines that it is a seborrheic keratosis and destroys it with cryosurgery. Use 702.1x (seborrheic keratosis) linked to the appropriate E/M code (with modifier -25 appended) and 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). Using the same diagnosis code for both is correct because the patient came in due to the itch and the surgery was performed to get rid of the itch.

The majority of minor surgical procedures performed by FPs have a 0- or 10-day global period, Sissom says. If a patient comes in specifically to have a skin lesion removed or biopsied, other related encounters within that 10-day period are bundled into the code for the surgery. But when a regular office visit turns into a minor procedure, you can still code for the office visit separately despite the 0- or 10-day global period, as long as you use modifier -25. This is because the initial office visit was not related to the procedure. It is a separate service and thus not a part of the global period.
 
For example, a 65-year-old man presents to manage his high cholesterol, and the physician finds four skin lesions on his back. The FP destroys the lesions via electrosurgery during that visit. Although this type of removal has a 10-day global period, you can also code for the E/M visit because it was for a different reason. In this scenario, use 17000* and 17003 ( second through 14 lesions, each [list separately in addition to code for first lesion]) and the appropriate code for an office visit with modifier -25 attached.