Town & Country Pediatrics & Posted Wed 15th of January, 2014 15:25:05 PM
A patient came in because he had an abscess on his finger (no other problems). The pediatrician drained and treated the abscess and billed both '10060' and an E/M code - level 4. Is this correct, or are the two codes mutually exclusive? The insurance company paid for both codes. Does it make a difference if it's a new patient?
SuperCoder Answered Thu 16th of January, 2014 06:38:45 AM
Yes for the E/M
modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99284 to show that the E/M and aspiration were separate services
Town & Country Pediatrics & Posted Thu 16th of January, 2014 10:47:30 AM
Can you please clarify your response because I am not understanding. The doctor wants to bill '99214' and '10060'. I'm not sure where the '99284' comes in. As far as I know there was only one procedure done, treating the abscess. What would the E/M code be for? It sounds to me like double-dipping.
SuperCoder Answered Fri 17th of January, 2014 09:53:10 AM
It's hard to say without seeing the E/M note, but in most cases, draining the abscess includes the services that would go into the E/M visit. When looking at the documentation, do you see a significant, separately identifiable E/M service documented, in addition to the note for the drainage? If not, you cannot bill the E/M code with the 10060.
Town & Country Pediatrics & Posted Wed 29th of January, 2014 12:50:12 PM
I don't see anything else in the note, but can you verify please?
RIGHT SECOND FINGER WITH SMALL PUSTULE WITH SURROUNDING ERYTHEMA TO PAPLMAR ASPECT OF AREA BETWEEN PIP AND DIP JOINTS. TENDER TO TOUCH, MOM EXPRESSED PUS FROM LESION YESTERDAY, STATES LESION MUCH LESS SWOLEEN TODAY.
Assessment & Plan:
# UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER (681.00):
Instructions printed and provided to patient:
PRESCRIBE: Omnicef 250 mg/5 mL oral liquid, 1/2 TSP QD X 10 DAYS, # 25, RF: 0
LANCED, TINY AMOUNT OF PUS/BLOOD EPRESSED, TO LAB FOR CULTURE
WARM SOAPY SOAKS AS TOLERATED"
Should we send a corrected claim to the insurance company removing one of the codes (either the 10600 or the 99214)?
SuperCoder Answered Mon 03rd of February, 2014 09:53:01 AM
Is this the entire note? If you have a history section, can we see that as well? If this is all of it, however, you can't justify the 99214. You should let the insurance company know that you're sending a corrected claim.
Town & Country Pediatrics & Posted Thu 13th of February, 2014 11:53:54 AM
I don't have the history section yet, but I just wanted to ask you about the following idea: the doctor is suggesting that the 99214 is still billable together with the surgery, because it would cover the decision-making, the actual diagnosis of the problem and the need for surgery, isolating it from other causes, and accounting for potential complications, etc. If he would refer to a surgeon, he (the pediatrician) would still bill the 99214 for looking at the finger.
SuperCoder Answered Fri 14th of February, 2014 10:47:35 AM
Hi there - I'm not seeing a 99214 covered here - the most I could justify without seeing the history section is a 99212, and you'll have to append modifier 25 to that. Unless your doctor is billing the E/M based on time (which he may have documented elsewhere but it isn't in the documentation you've shown us), this note just doesn't meet the criteria for a 99214. Which elements of history, physical, and MDM has he counted that add up to 99214? Feel free to email me directly if you'd like to discuss this offline. Thank you!
Torrey Kim, CPC, CGSC
Editor-in-Chief, Pediatric Coding Alert