coding & reimbursement
Office Visits with Minor Procedures
In some cases the exam can be billed as well.
By Suzanne L. Corcoran, COE

When you perform minor surgical procedures in the office, the exam performed that same day is usually considered incidental and not paid separately. However, there are exceptions.

Q: What constitutes a "minor surgical procedure?" Medicare defines these as procedures with zero or 10-day postoperative periods. Examples include foreign body removal (65222), punctal occlusion with plugs (68761), and epilation for correction of trichiasis (67820).

Q: When can I bill for an exam on the same day as a minor procedure? You can do so when the patient's condition requires an additional service beyond the usual care provided as part of a procedure. When a separately identifiable service has been performed on the same day as a minor procedure, use modifier -25 with the exam (992xx or 920xx) or consultation code (9924x). CPT defines modifier -25 as referring to a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."

Note: If the only purpose of an exam is preoperative care, a claim for an office visit with modifier -25 would not be appropriate.

Q: Do I need to provide different diagnoses for the exam and the minor procedure?

No. The CPT definition of modifier -25 specifically states, "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided . . . different diagnoses are not required for reporting of the E/M services on the same date."

For example, suppose one of your patients presents with two chalazions: a large one on the right eye, and a small one on the left eye. You incise and drain the larger one and treat the small one with medications and warm compresses. Both the exam and the minor procedure carry the same diagnosis (i.e., 373.2). Nevertheless, the exam is reimbursable in addition to the procedure because you had to cope with more than one occurrence of the same problem.

Of course, if the patient has more than one problem being addressed at the visit, it's appropriate to use different diagnoses on the claim. For example, suppose your patient has systemic lupus erythematosus and is being followed for potential toxicity due to Plaquenil therapy.

During today's exam, the patient also complains of a strong foreign body sensation in both eyes that hasn't responded to artificial tears suggested by a pharmacist. Your examination identifies keratoconjunctivitis sicca and associated dry mouth. You diagnose secondary Sjogren's syndrome. Due to the severity of the condition, you recommend continuation of the artificial tears as well as punctal occlusion in the lower puncta. The plugs are inserted today, and another follow-up visit is scheduled in 2 weeks.

In this case, the primary ICD-9 code for the exam (710.0) is different from the code for punctal occlusion (710.2).

Q: Will billing for both exams and minor procedures increase my audit risk? Excessive use of modifier -25 will garner unwanted attention. Thorough documentation of the medical necessity for the visit as a separately identifiable service is the best defense against postpayment recriminations.

The exam and minor surgery may appear on the same page in the medical record, but we recommend providing a separate operative report for the surgery. It should contain the indications for the procedure, a description of the procedure and discharge instructions.

A clearly documented consent for the procedure should also be included. (A Minor Procedure Consent and Treatment form is available for download on our Web site at no charge.)

Suzanne Corcoran is vice president of Corcoran Consulting Group. You can reach her at (800) 399-6565 or at scorcoran@corcoranccg.com.