Wiki Modifier 25 for examining a separate but minor problem

[JesseL]

I had asked this before in the past but want to hear a little more opinion on this.

In the scenario for the modifier 25 to be use, the other problem must be significant and separate from the procedure.

I've read that in order for the other problem to be considered "significant" "This can be defined as a problem that requires considerable workup or treatment, or a problem that, if not addressed at today’s visit, would require the patient to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M service in addition to a procedure."

So based off of this definition. If a patient for example needed cryo surgery on a wart on the hand, but the patient also has concern of a mole on her face, which the doctor used her dermascope to examine and has deemed it benign, does that separate exam not qualify the use of modifier 25 as that is obviously a minor problem? Because its separate but not significant?

 

[Pathos]

Based on your post, I would bill an E/M visit for all services performed for this scenario, and skip the 17000 code. Wart cryo removal is low RVU also, and our Family docs typically bundle this procedure into the E/M visit, unless the patient only came in for the wart removal, and the doc didn't do/look at anything else.

Hope that helps!

 

[JesseL]

Based on your post, I would bill an E/M visit for all services performed for this scenario, and skip the 17000 code. Wart cryo removal is low RVU also, and our Family docs typically bundle this procedure into the E/M visit, unless the patient only came in for the wart removal, and the doc didn't do/look at anything else.

Hope that helps!

That doesn't seem like a good way of doing it since some people have insurance plans that have deductibles for procedures (surgery deductibles) but does not apply for E&M. IF going by your suggestion, I'd bill just 99213 but 17110 pays way more even though 99213 has a higher RVU..

 

[CatchTheWind]

Pathos, your doctors are engaging in billing abuse. You are not permitted to bundle the work of a procedure into the E/M code, because this violates the rule of billing to the highest level of specificity. If you want to bill for just an E/M (as a courtesy to the patient, or because it's an HMO and you don't have a referral to do the procedure) you could do that, but you would have to omit the work of the destruction from your level just as you would if you were billing the destruction.

Now, about whether or not it is "signficant," my personal opinion is that if it was a new problem (even a minor one) that the patient was concerned enough about to have a chief complaint and HPI about and it warranted an exam with a dermatoscope, I would bill it. On the other hand, if it were just something that the provider happened to notice during the exam and documented, then I would consider it incidental to the visit and not "sigificant" enough to bill.

 

[Pathos]

On the other hand, if it were just something that the provider happened to notice during the exam and documented, then I would consider it incidental to the visit and not "sigificant" enough to bill.

Typically this is their (fam. docs) scenario, which is why we haven't billed out the cryotherapy codes separately. Our dermatologist commonly bill out destruction codes however, which is typically the reason for the patient visit.

I should have expanded on my example and I see the confusion.

So I suppose this brings us to look at the big picture; what did the patient come to the doctor for? Once this is established then we can move onward from there.