Question: A patient came in for two punch biopsies due to dermatitis that wouldn’t clear after treatment for a few months.  The doctor thinks that he should be able to bill an E/M with the visit, but I say no.  Who is right?

 Answer:  I don’t like giving this answer, but it depends.  If the patient presented for the biopsies and nothing else was done, then the biopsies alone should be reported.  If the patient presented for the biopsies and the physician went over and above what is usually performed when a patient presents for biopsies, then an E/M may be warranted with modifier 25.  The question is what goes over and above?  Did the physician do an exam of more sites than s/he biopsied?  Did the physician also give the patient a prescription to help with the dermatitis with instructions on use?  Then reporting an E/M service would probably be warranted.  The global surgical package includes the decision for the procedure and pre-op evaluation and discussion with the patient, so the documentation must indicate that what the physician did at the visit went beyond that.  I often see that physicians actually do go above and beyond, but they do not document it.  This falls back to my old saying, “If you think it, ink it!”  With all of the payors watching claims with modifier 25, it is important to do a spot check on these in your practice to ensure that the documentation tells the entire story of the encounter.

*NOTE: This response is current in March 2024.  As guidelines and payor guidance may change, please be sure to check if it is still valid when you are reading this issue.

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