Author Topic: the more I read about E/M coding, the more I get conflicting/confusing answers  (Read 3575 times)


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I am new to Podiatry Billing and procedures.  I cannot seem to find a straight-forward answer anywhere with my issue.   I wish someone would help me with proper use of E/M codes 99201/99202, and 99211/99212.  I read where you should not bill these E/M codes on the same day as a procedure, unless it is a distinct, separately identifiable procedure by using modifier -25.  Well, what in heck does that mean for a new patient?   Separately identifiable from what?  from the patient's complaint or separately identifiable from a previous visit (if the patient is not new)?  Do ALL NEW patients get billed an E/M regardless of whether a procedure was performed or not?  (this is the most important question I have)
Scenario1 : NY medicare NEW patient office visit, 70 yr old man presents and  just wants his feet evaluated and long toenails cut, no pain, no complaints.  I'll do an evaluation and see 10 long thick mycotic nails, he does not have palpable pedal pulses, has absent hair and atrophic skin.  I cut his nails in the office at that time, how should I bill?  99202 AND 11721 q8, or just 11721 q8?  E/M pays more, am I to assume that if I just evaluated him and did nothing, I would get paid more by coding the E/M alone?  I read where I'm not supposed to bill E/M in lieu of a procedure, but is it OK if I prescribe a topical antifungal and tell him to come back another day for his nails to be cut to be able to code the E/M on that day?  I doubt a patient would ever come back if I sent him on his way without doing anything to his nails.
Scenario 2:  Same patient comes back another day, wants his nails cut again, no pain, no complaints, same as scenario 1 above, subsequent visit.  Would I bill 99211 and 11721 q8   or just the 11721 q8?  (This situation I can understand that no E/M should be coded, just want to be sure, since I am indeed evaluating him again for the same issue)
Scenario 3:  Another new first-time patient (for simplicity, presents with same single complaint of long thick nails), upon evaluation I see no pulses, no hair, atrophic skin, he does have long thick mycotic nails, but he also has an ulcer under his 1st mpj (patient unaware of it).  I take care of his nails and debride his ulcer, non infected, clean wound base and teach him how to take care of it and tell him to follow up weekly.  how would I bill this, 99202, 11721 and 97597? or just the procedures 11721 and 97597?
You know what I wish?  I wish I could find scenarios with a complete showing of what would get billed to medicare.  I mean, complete visit notes and complete cms-1500 forms that would go with that visit.  I've seen contradicting or incomplete advice online regarding E/M billing.  I've been to a couple of coding seminars, but they get broken down into what constitutes an E/M code, and then other podiatry CPTs, I never saw a complete encounter and coding example.  I confess I've been chicken to ask in a group of 200 podiatrists for a complete bill example.  I'd love to see a complete cms1500 form for a plain old, run-of-the-mill  new podiatry patient, and subsequent vists. 
Again, above all, my biggest question would be, do ALL new patients get billed an E/M code regardless of whether a procedure was performed or not? 
With all sincerity, thanks for your time.  I know I'm not alone in my frustrations with this, feel free to post this on your site if you think it would help others.


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ALL new patients get billed the appropriate new patient exam code based on complexity of the case.  If a procedure was done the same day, add the -25 modifier to the exam code.  You DID an exam in order to determine what procedure needed to be done.  And by-the-way, bravo for taking care of the patient the same day, not making them come back another day.  You should be paid for the exam and the procedure.

For established patients, if the complaint is the same, and it's close to the original exam, you may not get paid for the office visit, bill it (if you meet the criteria) with a -25 if it was separate from the procedure.  But bill all the procedures.

If it's been a while since the last exam, you SHOULD do an exam and bill with a -25 modifier, and bill the procedure.


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Vidia, please visit thios website for future E/M info as they offer free E/M webinars and much more.

I also have so information on when it is correct to use E/M codes with other CPT procedures and will send to you if you wish, it's pretty lengthy so it wont allow me to post on here, it also includes the codes to the scenariso you provided.

Of all coding procedures E/M is by far the most frustrating for coders both young and new so you're not alone.  You may also want to pull your LCD because Medicare has some tricky guidelines when it comes to podiatry.
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare


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    • Professional Medical Billers Association
Michelle Rimmer, CHI, CPMB
President-Professional Medical Billers Association
Owner-ABA Therapy Billing Services
Author, 'Medical Billing 101' and 'Coding Basics: Understanding Medical Collections


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thanks guys/gals....much appreciated.