Primary Care Coding Alert

Question: If our FP performs a procedure like the debridement of nails, is it necessary to also report an E/M code for the pre-operative evaluation of the patient?

Colorado Subscriber

Answer: Like with many other procedures, you should not automatically report an E/M code for the evaluation of the patient prior to a nail debridement procedure. You will only report the E/M code when the E/M service is separate and significant from the procedure being performed.

If the E/M service is significant and separately identifiable from the work of the nail debridement, you will report the nail debridement with either code 11720 (Debridement of nail[s] by any method[s]; 1 to 5) or code 11721 (Debridement of nail[s] by any method[s]; 6 or more), depending on the number of nails involved, and the office visit with an appropriate E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …). You would attach 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) to 99213 to indicate the separate service.

You will need to report a relevant diagnosis, such as diabetes to its most specific form, along with any complication or other co-morbid condition, to support the medical necessity of the nail debridement. As noted in the description of modifier 25 in CPT®, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.” If the E/M service did involve other diagnoses, they would further substantiate that the E/M service was significant and separately identifiable.

All procedures include a certain amount of evaluation and management. Thus, if the evaluation and management involved in the encounter was just to assess the nails and then the physician proceeded to do the debridement, you probably can’t bill both the debridement and an E/M service. The documentation should indicate which service(s) to bill.