Wiki E/M when Criteria not met?

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kle0204

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If a patient comes in, but they don't meet the criteria to bill for routine foot care procedures (i.e. nail debridement, callus removal, etc.), can I still bill out an office E/M (i.e 99212) since the patient was still seen and examined and was educated on their diabetes status and what to look out for by the podiatrist? Or would it be the 11721-GZ (no ABN on file) and an E/M shouldn't be billed at all?

Thank you!
 
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Hello, was an ABN obtain? if so I would use modifier GA- Indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability. No ABN then the GZ modifier and no E/M code since this visit was only for a routine foot care.
 
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joettamorales said:
Hello, was an ABN obtain? if so I would use modifier GA- Indicates that an ABN is on file and allows the provider to bill the patient if not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability. No ABN then the GZ modifier and no E/M code since this visit was only for a routine foot care.
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Got it! Thank you so much!
 
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If a patient comes in for foot care that is routine in nature and does not meet the requirements for coverage, an ABN is not needed as it is statitorily not covered. You are not required to send a claim for the service, it would be CASH pay. To code an E/M in the place of a non covered service is not appropriate. A lot of offices complicate this scenario. If the patient does not qualify for one reason or another, ie: came in too early, no systemic conditions, does not report pain...then it is CASH pay. Remember, all jurisdictions allow for the debridement of mycotic nails if the patient reports they are painful, but again, once every 60 days.
 
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podcoder70 said:
If a patient comes in for foot care that is routine in nature and does not meet the requirements for coverage, an ABN is not needed as it is statitorily not covered. You are not required to send a claim for the service, it would be CASH pay. To code an E/M in the place of a non covered service is not appropriate. A lot of offices complicate this scenario. If the patient does not qualify for one reason or another, ie: came in too early, no systemic conditions, does not report pain...then it is CASH pay. Remember, all jurisdictions allow for the debridement of mycotic nails if the patient reports they are painful, but again, once every 60 days.
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Ok, that definitely makes things simpler. Or as simple Podiatry could be haha. And just to make sure, this goes for commercial insurances too? Or at least the ones that follows Medicare guidelines?
 
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kle0204 said:
Ok, that definitely makes things simpler. Or as simple Podiatry could be haha. And just to make sure, this goes for commercial insurances too? Or at least the ones that follows Medicare guidelines?
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ABN is only for Medicare. Medicare advantage plans should follow the same coverage guidelines.
 
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