Wiki Issue with office visits and procedures

[AprilSueMadison]

The American Academy of Derm has the following on their website:
"A shave removal procedure, e.g. code 11311, does not include an E/M service in the physician work, and a separate E/M service submitted with a -25 modifier on the same date should not be bundled with the shave removal"

I have a patient who has come in with a suspicious lesion on their nose. I have an HPI that describes the lesion, how long it's been there, where it is, and symptoms.

The ROS included the face, the head and the patient's psychiatric orientation.

The exam showed a 1.5 cm blahblahblahblah blah spot on the patient's nose.

Patient was diagnosed with an irritated SK and a shave removal was done. 1.5 cm, CPT code 11312.

Going off of the AAD guidelines, does this mean I have an office visit, or do NOT have an office visit?

I'm tired of being confused.

 

[OCD_coder]

If I were in your situation, I would not go by the AAD guidelines, but the carrier for the patient as everyone of them view it differently and they would trump any direction from a specialty organization if they had a medical policy in place.

For Medicare/Medicaid: No

For commercial carriers: Maybe


Medicare guidelines from their LCD (LCD for Removal of Benign Skin Lesions (L27362):Medicare will not pay for a separate E & M service on the same day as a minor surgical procedure unless a documented significant and separately identifiable medical service is rendered. The service must be fully and clearly documented in the patient?s medical record and a modifier 25 should be used.

Medicare will not pay for a separate E & M service by the operating physician during the global period unless the service is for a medical problem unrelated to the surgical procedure. The service must be fully and clearly documented in the patient?s medical record.

If the beneficiary wishes one or more of these benign asymptomatic lesions removed for cosmetic purposes, the beneficiary becomes liable for the service rendered. The physician has the responsibility to notify the patient in advance that Medicare will not cover cosmetic dermatological surgery and that the beneficiary will be liable for the cost of the service. It is strongly advised that the beneficiary, by his or her signature, accept responsibility for payment. Charges should be clearly stated as well.

 

[AprilSueMadison]

You are wonderful.

That is exactly what I needed and I'm so stressed out right now, it never occurred to me to look at those particular guidelines.

Basically, since we brought in our auditor and I started coding correctly, our office visits have gone down. I had to run a bunch of reports showing the differences since I began coding and the auditor got involved. NOW I have to go to a meeting to explain it all next week. Basically they have me second guessing myself really badly and I know they are going to want proof of everything I'm telling them....again.

BUT...I'm putting together everything I can think of to prove my point and that I'm right that they don't automatically get a an office visit every time they see a patient.