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Internal Medicine Coding Alert

You Be the Coder:
Routinely Reporting E/M With 11721 Not Advised

Question: If our internal medicine provider performs a procedure like the debridement of nails, is it necessary to also report an E/M code for the pre-operative evaluation of the patient?

Cincinnati Subscriber

Answer: Like with many other procedures, you should not report an E/M code for the evaluation of the patient prior to a nail debridement procedure. You will only report the E/M code when the E/M service is separate and significant from the procedure being performed. 

If the E/M service is significant, you will report the nail debridement with code 11721 (Debridement of nail[s] by any method[s]; 6 or more) and the office visit with the 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …). You would attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to indicate the separate service.

You will need to report a relevant diagnosis, such as diabetes to its most specific form, along with any complication or other co-morbid condition, to support the medical necessity. 

If the E/M was just to assess the nails and then the physician decides to do the debridement, you can’t bill them both. The documentation would indicate which service to bill.