Modifier 25 use question- example

[king22]

I'm having a debate with another pod buddy of mine regarding use of a 25 modifier in this situation-

A patient returns to your office your treatment of a his diabetic foot ulcer. You perform a debridement and after you measure you realize that the wound hasn't progressed. You evaluate the patient's shoe gear and the rest of the limb for any ASOI or ischemic changes. You call the patient's home nursing service and give new orders verbally.

My belief is that all you can bill for is the debridement in this case since the post-debridement instructions (including offloading) are included in the debridement code, but he is arguing that you could bill for an E&M due to the extra work involved in speaking with the patient's nurse manager.

What's your opinions?

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[Pronation]

Evaluating the patient's "shoe gear" is at least a level 4 visit in my book.

 

[G0dFather]

I'm having a debate with another pod buddy of mine regarding use of a 25 modifier in this situation-

A patient returns to your office your treatment of a his diabetic foot ulcer. You perform a debridement and after you measure you realize that the wound hasn't progressed. You evaluate the patient's shoe gear and the rest of the limb for any ASOI or ischemic changes. You call the patient's home nursing service and give new orders verbally.

My belief is that all you can bill for is the debridement in this case since the post-debridement instructions (including offloading) are included in the debridement code, but he is arguing that you could bill for an E&M due to the extra work involved in speaking with the patient's nurse manager.

What's your opinions?

you are the correct one... not a new problem only a procedure code warranted

 

[king22]

you are the correct one... not a new problem only a procedure code warranted

The 2021 E&M updates reiterated that modifier 25 can be used with E&M and Procedure that have the same diagnosis, even if it's not a "new problem".

This is from the AMA guidelines "The physician or other qualified health care professional may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant separately identifiable E/M service. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date."

The issue here, I believe, is what is considered part of the debridement code's built in E&M component. I was always under the impression that things like offloading, dressing change instructions, etc were all part of the E&M component of the debridement code. I would believe that this would extend to verbal orders given to home nurses.

 

[dtrack22]

The issue here, I believe, is what is considered part of the debridement code's built in E&M component. I was always under the impression that things like offloading, dressing change instructions, etc were all part of the E&M component of the debridement code. I would believe that this would extend to verbal orders given to home nurses.

I would agree with you. Updating dressing orders to a facility or home health agency is not a separately identifiable e/m service. It’s bundled into the debridement CPT and reimbursement. I don’t see anything in the scenario you gave which suggests anything more than that was done.

 

[Feli]

Debride is for the wound... wider shoe (E&M) is for the bunion/exostosis/malleus/PVD/etc.
I would probably use a level 3 for that reason, but it's hard to generalize without the case yourself.

A pure debride and bandage with no change in plan, no imaging eval, no DME change, no Rx, etc is clearly not E&M.