Wiki 11402 billing with a 99214 on same date of procedure.

Create Wiki
C

chrisnewell

New
Messages
1
Location
Capistrano Beach, CA
Best answers
0
My physician wants to bill a 99214 with a modifier 25 along with 11402.

99214,25
11402

It is my understanding that an E&M code is already included in the 11402 on the same date of service as the 11402. There were no other diagnosis discussed and the only procedure preformed was the 11402. Am I reading the CPT surgical package definition incorrectly?
 
If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

99213-25 719.46
11402 239.2

Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

Unless the excision was planned before the day of the visit, I'd bill the office visit as well.
 
philipwells said:
If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

99213-25 719.46
11402 239.2

Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

Unless the excision was planned before the day of the visit, I'd bill the office visit as well.
Click to expand...

Even with this example I believe a separate E/M is not payable because the provider had only examined the area of the lesion and nothing else so only the excision will be payable because evaluating the lesion is included in that payment. It might be considered fraud to report the e/m with a symptom diagnosis when it's related to the procedure.
 
philipwells said:
If the 11402 was planned on an earlier visit than yes the 11402 is the only CPT that can be billed since that was the reason for the visit.

For example if the patient came in complaining of pain in his/her arm/leg where the lesion was, then the physician examined the patient and decided to remove the lesion, then you can bill the office visit with a 25 modifier and the excision.

99213-25 719.46
11402 239.2

Basically use the patient's chief complaint as the dx for the office visit and the diagnosed condition the dx for the excision.

Unless the excision was planned before the day of the visit, I'd bill the office visit as well.
Click to expand...
First, an excision cannot be billed without the path report as you will not know if it is benign or malignant until the path comes back,
The 239 dx codes cannot be used until after the provider states this is a tumor or a growth, the definition in the code book states the term "mass" ( in quotes that means as well as similar terms) is not to be regarded as neoplastic.
If the patient did present with pain at the site of the skin abnormality you would not use the 719.4- code as that is a musculoskeletal code.
Also you cannot use the symptom to support one thing and the definitive to support a different part. The guidelines state that once a definitive dx has been rendered you do not code the symptom.
The 25 modifier states that it is not required that you have two separate dx codes to support its use.
The documentation must support that the provider examined the patient over above and beyond what was necessary for the procedure in order to bill the visit level and the procedure, the information provided by the poster here does not support this, you should bill the procedure only, after the path report is returned.
 
Last edited:
You must log in or register to reply here.
Top