Coding and Billing for E&M Services and Procedures: A Comprehensive Guide, Lecture notes of Medical Sciences

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Coding an Evaluation and

Management with a Procedure

David J Freedman, DPM, FASPS, FACFAS, CPC, CPMA

Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC

Procedure

E & M

25 Modifier

• Significant, separately identifiable E&M at same

encounter as a procedure

• Goes on the E&M code
• 25 Modifier never goes on procedure code

One Problem gets E&M and Another

Problem gets Procedure

• “Medicare” Patient scheduled for at-risk foot care who is

found to have tinea pedis

• Procedure to trim dystrophic toenails
• E&M - Tinea Pedis

One Problem Gets E&M and Another

Problem Gets Procedure

• Patient scheduled for biopsy and they say heel has been hurting.
• Procedure for punch biopsy
• E&M Plus X-ray-plantar fasciitis with stretching, ice, and dispense insert

One Problem Gets E&M and Another

Problem Gets Procedure

• Patient scheduled for biopsy and they say heel has been hurting.
• Procedure for punch biopsy
• E&M Plus X-ray-plantar fasciitis with stretching, ice, and dispense insert ICD-10 Codes:
• 1 – D49. 2 Neoplasm of unspecified behavior of skin
• 2- M79.671 Pain right foot
• 3 – M72.2 Plantar fasciitis

CPT Codes:

• 1 ,2– CPT 11104 – RT

• 3,2 – CPT 99213 - 25 modifier
• 3 – CPT 73630-RT

New Patient

• Ingrown toenail requires a procedure-removal

E&M working up the patient for this initial

encounter for a new problem requiring a

procedure.

ICD-10 Codes:

• 1 – M79.675 Pain in left toe
• 2 – L60.0 Ingrowing nail

CPT Codes:

• 2,1– CPT 99202

• 2 – CPT 11730 - TA

Initial Encounter-New patient

• Neuroma with x-ray and injection

Established Patient with a “New”

Problem

• Someone treated for plantar fasciitis 8 months ago

comes in with an ingrown left hallux nail

Established Patient with a “New”

Problem

• Someone treated for plantar fasciitis 8 months ago comes in with an ingrown left hallux nail

ICD-10 Diagnosis Codes:

• 1 – M79.675 Pain in left toe
• 2 – L60.0 Ingrowing nail

CPT Codes:

• 2,1– CPT 99213 – 25 mod
• 2 – CPT 11730 – TA