Since most Medicare Advantage plans use Medicare guidelines for coding, you should only bill the G0438 and not the 99397. Of course, the 99213 can only be billed if there is a truly significant and separately identifiable problem-oriented E/M documented (preferably in a separate note) that meets the requirements for the 99213. CPT guidelines state that modifier -25 should be added to the 99213. Also, the -25 modifier would need to be added to the 99213 for the 17000/17004 services. I would suggest that it might not be a bad idea to add -25 to the g0438, just to be sure that they don't deny anything as bundled.
Without documentation, I cannot say if it is truly appropriate to bill the 99213-25. If the reason for this problem-oriented E/M is the premalignant lesions, it may not be appropriate. Remember that the global payment of procedure codes include pre- and post- procedural work. The following is a good reference to use when applying modifier -25 for a procedure:
“The CPT codes for procedures do include the evaluation services necessary prior to the performance of the procedure (eg, assessing the site/condition of the problem area, explaining the procedure . . . discussion of probable diagnoses . . . {explaining} risks and benefits . . . expected result or scar . . . obtaining informed consent) . . . instruction of the patient/family on postoperative wound care, dressing changes and follow-up, instructions given to patient on how to recognize significant complications (eg, bleeding, or allergic reaction to antibiotic ointment or adhesive dressing), when results will be available and how they will be communicated, completion of medical records, and communication of results to referring physician, as appropriate . . . however, when significant and identifiable (ie, key components/counseling) E/M services are performed, these services are not included in the descriptor for the procedure or service performed.” (CPT Assistant 9/98)
HOWEVER, Medicare does make a separate distinction saying:
“The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier -25” (NCCI Manual)
And an article in March 2012 CPT Assistant indicates that CPT's policy is shifting towards Medicare's.
Karen
CCS-P, CPC, CPB, CPMA, CPC-I