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E/M charge with laceration repair


The patient came in to clinic to have wound checked to see if it needed sutures.  FNP assessed that yes he needed sutures.  The NP did not evaluate anything else.  The FNP insists we charge for lac repair and E/M.  This is Medicare Fraud, correct?

I do not believe it is fraud to bill for both as long as they are coded correctly.  The only dxs on the claim should be regarding the wound.  Then Medicare can determine if they allow the E/M separate from the sutures.  Are you the biller?  Or the coder?  or both?  Medicare will not pay the E/M visit unless it has the 25 modifier appended.  Whoever is coding needs to determine if it would be appropriate to append the 25 modifier.  If not then the two codes can be submitted but they will bundle the E/M in with the sutures.  So it really isn't doing anything fraudulent.  Both services were provided, and Medicare will determine if they should be bundled or not.  As long as the coding matches the information in the patient's chart there is nothing wrong. 

Thank you for your response.  I am the coder, and modifier 25 does not work for this scenario.  I understood a laceration repair as having an inherent E/M service.  Is that right?  Nothing else was addressed by the FNP. 

I am a biller, not a certified coder, but I do have a lot of experience in coding (over 25 years).  The basic description of the code does not state that the E/M service is included however, I do agree with you.  With that being said, I do not believe it is fraudulent to bill for the E/M since you are not appending the 25 modifier.  It will most likely be denied or bundled.  If you were including other dxs &/or using the 25 modifier then that would be fraudulent.  If the provider (FNP) is insisting you bill both codes I think I would go ahead since the information regarding the codes is accurate and documented in the chart. If in fact the E/M is inherent to the laceration repair the insurance carrier will simply bundle and state that .

In response to this and your question about E/M and cryotherapy, the simplest thing to do, and this is what I tell doctors/coders:

Audit the treatment note and remove everything relating to the procedure, since an E/M component is already factored into the RVU's for the procedure. Whatever you have left over will determine if you have the elements necessary to bill an E/M. This applies to new and established patients both. If you do have the elements, then determine your level of E/M accordingly, and bill it with a 25 modifier. If you don't have the elements needed, then just bill the procedure performed. As with everything, there are rare exceptions to this...such as if you can use time as an element with the appropriate documentation of time spent face to face with patient and nature of the counseling/coordination of care. Generally though, if the only thing addressed at the time of service is related to the procedure, you will not have a separate, significantly identifiable E/M.


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