Primary Care Coding Alert

See how you rationale stacks up to these experts' opinions

You should be able to bill for an E/M that's related to a same-day procedure as long as you do more work than the usual -no or go- preoperative examination.

When a patient comes in with a new problem and the physician examines the patient, then performs a minor procedure to correct the problem, determining whether the E/M service warrants reporting can be tricky.

Apply the principles discussed in -These Tips Help You Decide if Destruction, I&D Visits Also Warrant E/M Service- to the following examples.

An Unrelated Problem Generally Supports Modifier 25

1. Laceration repair: If a patient has fallen and cut his forehead open, and the doctor merely glances at the wound and confirms that it needs stitches, the doctor shouldn't bill for an E/M separate from the stitching, says Quinten A. Buechner, MS, MDiv, CPC, president of ProActive Consultants LLC in Cumberland, Wis. But if the physician checks the patient for concussion and other problems before stitching, the documentation of that supports a separate E/M.

2. Cerumen removal: On the other hand, the cerumen removal scenarios that appeared in the June 2006 Family Practice Coding Alert article -Tried-and-True Tips Turn Denials Into 9921x + 69210 Payments- contain separate diagnoses--a factor that, although not required, makes justifying a separate E/M service easier.

The scenarios all dealt with patients who did not present for scheduled cerumen removal. In these cases, -the documentation of the chief complaint, a history of the patient's medical conditions, the examination of more than the ear, and a medical decision to remove the impacted cerumen warrant an E/M service in addition to the cerumen removal,- says Steven M. Verno, CMBSI, director of reimbursement for Emergency Medical Specialists in Hollywood, Fla.

Appropriate diagnoses that may warrant a separate E/M service from cerumen removal include ear pain (388.7x, Otalgia), otitis media (381.00-382.9), or another illness (such as 465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site).

3. Arthrocentesis: The author of Coding With Modifiers, Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president of Medical Professionals Inc. in Indianapolis, is more conservative.

She gives this example: A patient comes in with knee pain (719.48, Pain in joint; other specified sites). The physician diagnoses fluid in the joint and then performs an arthrocentesis (20610, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]).
 
If the patient also needs diabetes counseling, you can report the counseling separately and attach modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M to receive payment for this service and the procedure. 

But if the physician only examines and diagnoses the patient's knee pain and decides to perform an arthrocentesis, you should consider the exam a pre-operative workup and only bill for the procedure, Grider says.

New Workup Before Procedure May Be Codeable

Although this is a gray area, you should be able to use modifier 25 with a -new-onset problem- that requires a workup and then leads to a procedure, says Jo Ann Steigerwald, RHIT, senior consultant with the Wellington Group in Valley View, Ohio. For example, if a patient comes in with bursitis (726.69, Enthesopathy of knee; other), the doctor needs to examine the patient and then explain why he must perform the necessary procedure.

Expert Advice Goes 2 Ways

4 and 5: Wart Removal and I&D: If you apply Grider's and Steigerwald's rationales to the previously mentioned Family Practice Coding Alert Reader Questions on wart removal and I&D, it's easy to see that contradictory advice could be accurate.

In both cases, the FPs had to work up a new-onset problem (non-healing spot and testicular pain) that led to the procedures (wart destruction and I&D). If the physicians documented more than the usual pre and post-op care associated with 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) and 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), a separate E/M code would be justified.

-The FP's documentation should support the E/M service as significant and separately identifiable from the same-day wart destruction,- the June reader question said.

But some experts may err on the conservative side and recommend not separately reporting an E/M service in addition to the I&D. If in doubt about separately reporting an E/M service with the same diagnosis as a procedure done at the same encounter, ask your FP whether he thinks he documented more than the normal pre- and postoperative evaluation associated with the procedure and make sure that documentation supports the level of E/M service being reported.