Primary Care Coding Alert

Are you having trouble deciding when to charge 99201-99215 with 17000-17111? Coding experts answer your toughest questions regarding reporting a same-day service and lesion destruction.
 
Each insurer has its own guidelines for office visits (99201-99215, Office or other outpatient visit ...) and wart removal (17000-17111, Destruction, benign or premalignant lesions), says Susan D. Sajdyk, CPC, a dermatology-family physician billing specialist at Memorial Physicians Inc. in Marysville, Ohio. So, knowing whether to appeal an E/M denial is difficult unless you know that the service deserves payment.

When Should You Charge an E/M?

You should report the office visit (99201-99215) in addition to the procedure when the family physician performs a significant, separately identifiable E/M services from the wart removal. If a patient comes in for an initial wart removal visit, you should charge an E/M service, Sajdyk says: "The physician has to examine the area, discuss treatment options and perform the removal."
 
When the patient comes in for a retreatment, and the FP doesn't do anything other than the retreatment, you should not typically report an office visit, Sajdyk adds.
 
To show the payer that the E/M is a significant, separately identifiable service, encourage your FP to write different paragraphs for the office visit and wart removal, Sajdyk says. Documentation tip: Document the history, physical examination, assessment and plan in one paragraph. The second paragraph should describe the wart's location, appearance, and removal method. In addition, the notes should include a diagram of the affected body parts.
 
If this is the first time billing the particular insurer, send in the chart notes with the diagram. "That way, you'll know right off the bat whether the payer is going to deny the claim," Sajdyk says. Supplying the additional up-front documentation pays off in easier reimbursement.
 
Keep a chart of insurers that routinely deny the same-day E/M. When a patient with a carrier that bundles the E/M into the office visit, such as Oxford, comes in for wart removal, you can inform him that the insurer will probably deny the service. In this case, you should bill the patient for the charge if your contract allows you to.

Do You Need Modifier -25 on the Office Visit?

 Although many insurers including Medicare require modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on claims for same-day E/Ms and procedures, not all payers mandate using the modifier. If the FP does something not related to a wart, such as evaluating dermatitis (692.9, Contact dermatitis and other eczema; unspecified cause), you should use modifier -25 on the E/M, Sajdyk says.
 
Wart removal and E/M example: During a preventive medicine service, a 30-year-old established male patient points to a bump on his hand. The FP offers to remove the wart with cryotherapy. The patient agrees, and the physician applies liquid nitrogen to the common wart and informs him that the wart will probably fall off in about a week. You should report 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) for the common wart removal. You should append modifier -25 to 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... 18-39 years) for the well check to show that the office visit is a significant, separately identifiable service from 17000.
 
Watch out: Some payers, such as Amerihealth HMO, set up their computer systems automatically to reject any E/M procedure claims that do not contain modifier -25, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.
 
Medicare also requires modifier -25 to denote the work that was necessary based on the patient's condition and then resulted in the wart removal, says Dalrona Harrison, RN, BS, CCS-P, CPC, associate director for precertification and authorization at Preferred Health Systems in Wichita, Kan.
 
Should You Report Separate Diagnoses?

CPT and Medicare do not require different diagnoses to use modifier -25, Callaway says. To avoid later accusations of inappropriate coding, don't "tweak" ICD-9 coding, she says. You should instead code accurately.
 
If separate diagnoses, such as acne (706.1, Diseases of sebaceous glands; other acne) and viral warts (078.10, Other diseases due to viruses and Chlamydiae; viral warts, unspecified), exist, use them. Reporting different diagnoses can cut down on insurance company scrutiny, says Paula Walczyk, office manager at Family Health Partners in Davenport, Iowa.