Wiki Is this realy significant same day?

[Sarah Ann]

Hello!

I could be missing something (please feel free to let me know)
This is an account from urgent care

A Person came in for a tick bite:

S40861A as admitting and principle (bite right upper arm initial encounter)
W57XXXA secondary bitten arthropod-ext. cause.

I coded the retained organic fragments Z1839

Additionally I coded a procedure for removal of a foreign body 10120 incision and removal of foreign body-simple. That's it just the procedure.

The physician just sent off a Lyme AB to the lab instead of doing the Lyme prophylaxis because the person had antibiotic allergies.





I did NOT code a professional E/M with a modifier 25, and was questioned about this.
The patient was here for a tick bite, they decided to remove the reminants of the tick.
Sent blood for a Lyme AB.

We also code for the tech. side-so the blood sent to the lab is covered on our facility side.
Am I missing something here? I'm not seeing anything else that was treated/assessed beyond the person coming in for a tick bite, there's nothing more that warrants a separate E/M with a modifier 25.

OR did I miss something right in front of my face?
Thanks!

 

[AlaskanCoder]

My feeling is that you have coded this correctly and ethically. However, I cannot say with absolute certainty without seeing the documentation. The "separately identifiable" portion is not dependent on the diagnosis(es), you could have a separately identifiable E/M with the same diagnosis as the procedure. However, many providers (and coder/billers) do not understand all that is included in a CPT procedural code. With the exception of procedures which have a zero day global and add-on codes, labs and radiology (XXX globals), the global period includes the pre- and post- procedural work involved. The following is one of my favorite references that I give to my providers, co-workers and students:

“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)

Karen
CCS-P, CPC, CPB, CPMA, CPC-I

 

[thomas7331]

I'd agree that it's really necessary to see the documentation to make a determination if the E/M and modifier 25 would be supported. However, I would argue that the E/M and modifier are likely OK - if the patient is being evaluated and tested for possible exposure to Lyme disease, that is already in an of itself a separately identifiable problem from the normal perioperative procedural work of a foreign body removal - to evaluate for the infectious disease requires additional work that would not be necessary if the patient was simply presenting for this procedure. This wouldn't be the case if, for example, the patient had been previously evaluated by a provider then sent to a specialist for the procedure, in which case, there wouldn't likely be reason to perform another evaluation other than what is required for the procedure.

I would question the use of the surgical code for the removal of a tick - this doesn't normally require an incisional procedure, but again, you can't really say without seeing documentation.

 

[HangarPilot]

I just recently when down this road with removal of a foreign body (FB) from an ear...

Standing "policy" was that if a patient came in for something like a umbilical granuloma and we did a cauterization, we "could not" bill for both the E/M and the cauterization on the same dx code. So, if the provider only coded the granuloma, we would bill for the cauterization only. If there was anything else (e.g. jaundice), then we would also bill an E/M linked with that dx. It was one of those "we've always done it this way" stories (no doubt based on some carrier denying claims). I didn't necessarily agree ... but as an "A" can't argue too much.

Then a child came in with ear pain. It was ultimately determined there was a bug in their ear that the provider removed. With only one dx (FB in ear) if I followed "policy" I could only bill for the 69200 FB Removal. But I didn't like that ... the chart clearly showed a "typical" visit... It's not like the kid walked in with a known FB in the ear and asked for removal. The provider clearly did "work" and did the history, ROS, exam, etc. (has he been swimming? any sick contacts? bla bla bla). Sure, in hindsight one could say "it was just a FB" ... but the provider didn't know that and had to determine which of the numerous causes for ear pain we were dealing with.

So, I made my case. I felt the E/M was justified based on the documentation (not just the dx). I argued it would be inappropriate to try and bill an E/M based on "ear pain" or something because that's "part and parcel" to the fact they have a bug in their ear! I even found a note in AAPC Coder with a similar scenario saying to bill both with the same FB dx. I got a reluctant "go ahead and try" ... and the claim was paid! Score!

I said all of that to say ... I agree that it comes down to the documentation. An E/M is turning a provider's "cognitive effort" into money. Was work involved? If a parent walks in with a child with a bleeding belly button and the provider walks in and says "yep, she sprung a leak" and cauterizes it ... no real "work" was involved outside the cauterization so no E/M.

 

[Sarah Ann]

I'd agree that it's really necessary to see the documentation to make a determination if the E/M and modifier 25 would be supported. However, I would argue that the E/M and modifier are likely OK - if the patient is being evaluated and tested for possible exposure to Lyme disease, that is already in an of itself a separately identifiable problem from the normal perioperative procedural work of a foreign body removal - to evaluate for the infectious disease requires additional work that would not be necessary if the patient was simply presenting for this procedure. This wouldn't be the case if, for example, the patient had been previously evaluated by a provider then sent to a specialist for the procedure, in which case, there wouldn't likely be reason to perform another evaluation other than what is required for the procedure.

I would question the use of the surgical code for the removal of a tick - this doesn't normally require an incisional procedure, but again, you can't really say without seeing documentation.

Duh, I should have prefaced it with a little more info!!!!! It was incised I can't remember because they thought it was something else. You're correct a plain incision/ removal of a fb 10120-it went beyond the just the procedure. If you just removed a foreign body there would be no need to order Lyme testing. So that's where it would be appropriate to add the 25. Thanks!!