Primary Care Coding Alert

Question: I know that if an established patient makes an appointment to have a wart removed, and he has had other warts removed recently, we can only bill for the wart removal. But, what if the patient makes an appointment for wart removal but has not been previously treated for warts? The FP will have to evaluate the problem before it is treated; can we then bill for an E/M visit as well?

Wisconsin Subscriber

Answer: CPT rules allow that sometimes, when the physician performs a procedure or service, the patient's condition requires a significant, separately identifiable E/M service above and beyond other services provided (or beyond the usual preservice and postservice care associated with the procedure that was performed). The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. You can report this circumstance by adding 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 appropriate level of E/M service. For such situations, CPT states, "As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date."

Thus, in your example, if the physician performs and documents the work otherwise associated with an E/M service (e.g., gets some history on the condition, examines the patient and decides to remove the warts as requested by the patient) and then proceeds to remove the warts at that encounter, he can appropriately code an E/M (e.g., 99212) in addition to coding for the wart removal (e.g., 17110*, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of flat warts, molluscum contagiosum, or milia; up to 14 lesions). To do so, he must add modifier -25 to the E/M code.

As noted, different diagnoses are not required for modifier -25, so the fact that both the E/M and procedure code in this example probably have a diagnosis of warts (e.g., 078.10, Viral warts, unspecified) should not be a problem.

Answered by Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians.