Wiki E/M service same day of MOHS

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Texascoder64

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Does anyone code for a dr that wants to charge an E/M same day of MOHS surgery ?
This is a dilemma for me as the Dr finds something unrelated to code (i.e., 702.11 Seb Keratosis) then the rest of the claim is the mohs surgery. I have the problem when a 90 day p/o global such as a Flap or Graft -and insurance will most certainly deny the e/m. I have used 57 mod (because of the major surg. codes) and even tried 25 - since the e/m was not a decision about the MOHS it was just an examination of an SK or AK.
My thought is really?? this can wait, don't mess up my clean claim. LOL..
Can anyone give me some input on this. Am I just out of luck and have to appeal the ov denial and try to prove the dr looked at a spot?

thanks
 
Tracy, this is the initial claim for the mohs surgery and is not in a p/o global.
Insurance will deny 25 on the e/m because a major code such as flap or graft is on the claim. So when I use 57 it also denies. Basically - Medicare wants us to prove a separate problem was really seen on the day of mohs.

So my question is - I know I will have to appeal this anyway, but which e/m modifier is correct 25 or 57.
because the claim has a combination of minor and major codes - so which one to pick?
 
Texascoder64 said:
Tracy, this is the initial claim for the mohs surgery and is not in a p/o global.
Insurance will deny 25 on the e/m because a major code such as flap or graft is on the claim. So when I use 57 it also denies. Basically - Medicare wants us to prove a separate problem was really seen on the day of mohs.

So my question is - I know I will have to appeal this anyway, but which e/m modifier is correct 25 or 57.
because the claim has a combination of minor and major codes - so which one to pick?
Click to expand...


Sorry about that...I read the original question differently!

My thought is that the -25 modifier would be most correct for this claim:

Modifier 25 as a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Usually I would recommend the -57 modifier, due to the fact that the Mohs procedure is a major procedure, but as you mentioned, the decision to do the Mohs was not made at this visit. I do agree that you will need to appeal this as well. Good luck!
 
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