Wiki History Codes used as DX for F/U Office Visits????

[LBernat7]

I have recently seen several of the following scineros and I just wanted to get some clarification:

Patient comes in and has a full skin exam and Z12.83 is used as well as all applicable history codes (say Z85.828 hx of BCC or Z85.820) on the office visit that day and maybe the patient has Biopsy done (11100)

Now as a result of the BX on visit #1 pt comes back and needs to have an excision and repair or say a shave excise approx. 1 month later. This time dr codes for the procedure he or she does and codes an office visit but only with History codes.

Nothing has changed and my thought was they came in for the procedure only and that's what the notes state simply because the patient possesses a history they are charging an office visit? Is this allowed? Clarification would be great thanks

 

[ellzeycoding]

Bunch of problems with your assumptions...

1. FIRST PROBLEM. You don't code for an E/M when they come back for the biopsy or the excision. Excisions are minor procedures and the E/M is included in the reimbursement for the minor procedure. You can only bill an E/M if it is separately identifiable (i.e., above and beyond any E/M related to the procedure or for a different problem).

This true for New and Established Patients. This is part of the National Correct Coding Initiative Guidelines.

In January 2013, CMS released updated instructions to the National Correct Coding Initiative (NCCI). In the Integumentary Section of these instructions, new guidelines and rules were provided on billing E/M visits (for both new and established patients) with minor procedures. A minor procedure is a code with 0 or 10 postop days.

Source: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html


On page III-3 of the Integumentary System 10000-19999 file, you will find the following instruction/rule change. Pay attention to the area(s) in bold.

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a 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.

The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles.” 



2. For the biopsy, usually code D49.2 or D48.5 to show medical necessity. You are unsure what it is, so you code one of these to show why you are taking it out. There is no need to hold for pathology on biopsy.

3. When the excision is done, you code the actual DX. If it came back as a basal cell carcinoma after biopsy, you bill the BCC diagnosis for the excision or removal. If came back as malignat melanoma, you bill that.

4. Down the road, if they are having a follow-up visit. let's say it's a 12-month skin check. THEN you use the personal history codes, because they have a previous history of having BCC or MM. Z85.820 to Z85.828

 

[LBernat7]

I understand all that what I was flagging is the patient who was here for an ED&C (destruction) based on a path from a previous visit when they had a full skin and biopsies done and the DR was charging History codes as a 99213 e/m visit? While the patient may have the history I see no way to charge an office visit when they were here for the procedure only espically since the previous visit was only 28 day ago and an office visit with histories were charges then correct?

Bunch of problems with your assumptions...

1. FIRST PROBLEM. You don't code for an E/M when they come back for the biopsy or the excision. Excisions are minor procedures and the E/M is included in the reimbursement for the minor procedure. You can only bill an E/M if it is separately identifiable (i.e., above and beyond any E/M related to the procedure or for a different problem).

This true for New and Established Patients. This is part of the National Correct Coding Initiative Guidelines.

In January 2013, CMS released updated instructions to the National Correct Coding Initiative (NCCI). In the Integumentary Section of these instructions, new guidelines and rules were provided on billing E/M visits (for both new and established patients) with minor procedures. A minor procedure is a code with 0 or 10 postop days.

Source: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html


On page III-3 of the Integumentary System 10000-19999 file, you will find the following instruction/rule change. Pay attention to the area(s) in bold.

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a 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.

The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles.” 



2. For the biopsy, usually code D49.2 or D48.5 to show medical necessity. You are unsure what it is, so you code one of these to show why you are taking it out. There is no need to hold for pathology on biopsy.

3. When the excision is done, you code the actual DX. If it came back as a basal cell carcinoma after biopsy, you bill the BCC diagnosis for the excision or removal. If came back as malignat melanoma, you bill that.

4. Down the road, if they are having a follow-up visit. let's say it's a 12-month skin check. THEN you use the personal history codes, because they have a previous history of having BCC or MM. Z85.820 to Z85.828

 

[mitchellde]

It does not sound like you have what is needed to be able to bill for the office visit. you would bill the destruction with the pathology diagnosis.
just a couple of other things:
if the patient has a history of cancer and is here for follow up you would not use a screening dx code you would use the Z08 code with the history of the neoplasm secondary. If the patient has symptoms that needs a procedure you would not use a screening dx code you would code the symptoms. Do not code the D48.5 just because the path report is not back or the procedure has not yet been performed. The code book tells you
•Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.
histologic confirmation means you must have a path report before these codes can be assigned.
D49 codes need specific documentation that after a preliminary diagnostic study (lab, radiology), the provider is unable to make a definitive diagnosis so they use terms like growth or tumor.

 

[LBernat7]

thanks

thanks for clarifying, that's exactly what I thought about not having the documentation for an office visit code.

The destruction or surgery or shave whatever it is coded with the path in hand so that's fine.

It does not sound like you have what is needed to be able to bill for the office visit. you would bill the destruction with the pathology diagnosis.
just a couple of other things:
if the patient has a history of cancer and is here for follow up you would not use a screening dx code you would use the Z08 code with the history of the neoplasm secondary. If the patient has symptoms that needs a procedure you would not use a screening dx code you would code the symptoms. Do not code the D48.5 just because the path report is not back or the procedure has not yet been performed. The code book tells you
•Categories D37-D44, and D48 classify by site neoplasms of uncertain behavior, i.e., histologic confirmation whether the neoplasm is malignant or benign cannot be made.
histologic confirmation means you must have a path report before these codes can be assigned.
D49 codes need specific documentation that after a preliminary diagnostic study (lab, radiology), the provider is unable to make a definitive diagnosis so they use terms like growth or tumor.