“I'm in PA, and this is an 80-year-old patient.....
His first visit to us, we billed:
99204-25 (B35.1, E11.621, E13.42, R60.1)
11721-Q8 (E11.51, B35.1, E13.42)
Cigna denied both charges stating the diagnosis codes do not support the procedure (as per what my billing company told me). This was before we were notified that notes must be sent in with all Cigna claims where an E&M is billed with a procedure. But I plan on sending them with the denial anyway.
Also, just to clarify, for new patients only, I thought we could bill an E&M and procedure using same diagnosis codes. Do I need to take the B35.1 off the E&M code? I still counseled the patient on his fungal nails and evaluated them prior to debriding them, but if that's what the issue is, I can take it off.
Another question, If I can use same diagnosis codes with E&M new patient and procedure codes, do I need to leave the 25 modifier off then?
Any advice is appreciated on how to recode / resubmit, or if this is Cigna's weird way of just saying they want the notes with OV + procedure claims, even though it was prior to their announcement. Thanks.”
The number one reason that podiatrists are audited and fail the audit is the inappropriate use of the 25 modifier, allowing an E/M service to be billed with a minor surgical procedure. A minor surgical procedure is a CPT/procedure code that has a global period of "0" or "10" days. This is from a Traditional Medicare position.
As time has progressed, this issue has been taken quite seriously by the Medicare Advantage Plans and the commercial health insurance carriers, as well. Until recently, whenever an E/M service with a 25 modifier appended was billed on the same date of service with a CPT/procedure code, it was not uncommon for one of the health insurance carriers mentioned above to automatically reject the E/M service and reimburse for the CPT/procedure code and challenge you to appeal their decision to not reimburse for the E/M service. This has now changed. The health insurance carriers are now requesting your medical record documentation whenever an E/M service is billed together with a CPT/procedure code. I still believe that they will reject the E/M service and challenge the providers to appeal the decision.
It is important to understand the following:
1. The 25 modifier is appended to an E/M service when it is billed on the same date of service as a minor surgical procedure to specifically indicate a SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE.
2. Every CPT/procedure code has an inherent E/M component.
3. It is up to the provider, through his/her documentation, to demonstrate the thought process that was used to separate the E/M component from the CPT/procedure code to make the E/M service significant and separately identifiable.
The same ICD-10-CM code(s) can be used for both the E/M service and the procedure on the initial visit. This can also take place on a subsequent visit as long as the patient is being evaluated and treated for a new problem that has not been addressed previously.
As far as seeing a patient for onychomycosis, it is appropriate to bill for the E/M service on the initial encounter that you are seeing the patient for this issue in addition to debriding the nails. If the medical record demonstrates that the patient was educated in detail on the issue of onychomycosis and what can be done to treat and hopefully eliminate the onychomycosis in addition to debriding the toenails because they are painful, etc., or because the patient qualifies for "At Risk," Routine Foot Care, this should qualify the E/M service appended by the 25 modifier for reimbursement. I would add to the documentation about the patient education, that this is a "significant and separately identifiable E/M service.”
Do not bill the E/M service without the 25 modifier. Aside from the fact that the E/M service would automatically not be reimbursed, you want to show the health insurance carrier why you are billing the E/M service. It is significant, and separately identifiable. That is why the 25 modifier is used.
Last point: Please be careful with the level of E/M service that you are billing for an onychomycosis encounter. 99204 is for a moderate risk of morbidity from additional diagnostic testing or treatment. Based upon the documentation and what the treatment entails, it would be 99203 at best.
This is my opinion.
Michael G. Warshaw, DPM
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