Wiki E/M and Separately Identifiable Service?

[774526]

Seeking opinions/thoughts re whether or not E/M as described below is separately identifiable and should be billed with an I&D (CPT 10061) procedure.

Basic info from previous visit - Patient seen for follow-up after undergoing incision and drainage of a new abscess site ....He denies any new areas of tenderness but has noticed a sebaceous cyst on the right side of his abdomen that he wishes to have removed in the near future.

Basic info visit in question:

Established patient – 36 yo

CC – I think I have an infection on that cyst

HPI – Patient seen 3 days ago & at that time did not exhibit any signs or symptoms of additional infections….patient says had previous treatment for pilonidal cyst abscess years ago when was a teenager

PE – Integumentary – Right lower abdominal flank tender, infected sebaceous cyst with fluctuance & surrounding induration…..

Plan – I recommend that the patient undergo I&D of site (procedure performed)

 

[csperoni]

I would not count this as a significant and separately identifiable E/M. All procedures (like 10061) include some credit for the work done just prior. There was no additional problem evaluated. No treatment other than the I&D.
Here's Noridian's guidance for -25: https://med.noridianmedicare.com/web/jeb/topics/modifiers/25
Note: "Do not use when documentation shows amount of work performed is consistent with that normally performed with procedure."

 

[774526]

I would not count this as a significant and separately identifiable E/M. All procedures (like 10061) include some credit for the work done just prior. There was no additional problem evaluated. No treatment other than the I&D.
Here's Noridian's guidance for -25: https://med.noridianmedicare.com/web/jeb/topics/modifiers/25
Note: "Do not use when documentation shows amount of work performed is consistent with that normally performed with procedure."

Thank you for your reply--this is very helpful. One quick f/u question--the provider also documented that he is prescribing Keflex and is considering a referral to infectious disease if infections continue- do you feel this additional information supports the E/M?-- I was trying to be concise in my original post and inadvertently left this part out.

 

[csperoni]

I would imagine provider would prescribe Keflex anyway - would not consider that separately identifiable. Same for considering a referral. Pt was seen 3 days prior. If the E/M elements included other body areas, other problems, etc -25 could be warranted. If the provider had sat down, discussed & documented the past 5 years of infections, and treatments of each of them, then you might have a case for -25.
Remember, it's not just "separately identifiable", but also "significant."
To me, even with Keflex rx and considering referral, that would still be work "normally performed with procedure."

 

[algates21]

I was taught if when he originally presented for the problem there was no infection but now there is and medication was prescribed, that's an additional problem complicating the original reason for presentation. Therefore there would be an e/m for that visit.