“I saw a patient with a history of chronic onychocryptosis. On this date of service, he presented with a red, swollen, tender right great toe. I performed an E/M and diagnosed paronychia L03.031 for which I took a culture for a gram stain and culture and sensitivity. I discussed the problem with the patient, prescribed an oral antibiotic and gave him instructions. I billed CPT 99213-25 for this. During the same visit, I addressed hypergranulation tissue L92.9 of the same toe. I treated it by excising the tissue and cauterizing the area with silver nitrate. I billed CPT 17250. I was told that HMO Blue of Massachusetts retracted the office visit due to an audit and that there are no appeal rights. Insurance states that “there are no other issues managed and treated aside from the procedure. Therefore the documentation does not support a separate E&M level of service.” I would appreciate any insights you have on this situation, especially when I am informed that I have no appeal rights.”
This appears to be an example of same story, different characters. The patient presented with a paronychia of the right great toe. A C&S was obtained and the patient was prescribed an antibiotic and was provided with instructions. This was billed with an E/M code, 99213. Additionally, there was a granuloma present on the same toe. The granuloma was addressed by excising the pathologic tissue and then cauterizing the affected area with silver nitrate. The CPT code that was billed was 17250 which is defined as: Chemical cauterization of granulation tissue (proud flesh, sinus or fistula). Since the E/M code was performed in conjunction with the minor surgical procedure code CPT 17250, the 25 modifier was appended to the E/M 99213 to indicate a significant, separately identifiable E/M service. Well, is the E/M service significant and separately identifiable?
It is not unusual for a patient that has a toe with a history of chronic onychocryptosis to present with a red, swollen, tender toe that can certainly be diagnosed as a paronychia. It is also not unusual for the onychocryptosis with the paronychia to be so advanced that it has developed a granuloma on the same side of the affected toe. It would appear that the onychocryptosis, the paronychia and the granuloma are all related. Therefore, it would not be appropriate to append the 25 modifier to E/M code 99213 as demonstrated in the above post as the E/M service is truly not significant and separately identifiable from the procedure that was performed, CPT 17250.
Unfortunately, even if the E/M service was clearly NOT related to the procedure that was performed at the same encounter, since the health insurance carrier is a commercial HMO, the likelihood that both the E/M service and the procedure would have been reimbursed is slim to none. With respect to this health insurance carrier, there were no rights to an appeal. As I have said in the past, depending upon the health insurance carrier, the best way to avoid this scenario is not to bill the E/M service and the procedure on the same date of service if medically possible. Today’s situation did not offer this option.
This is my opinion.
Michael G. Warshaw
DPM, CPC
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