Stratum Corneum

Question:

What CPT code do I use for the sampling of the Stratum Corneum?  I have searched everywhere and cannot find a code.

Answer:

The sampling of the stratum corneum by any method, is not a biopsy. Skin scraping or tape stripping is not considered a biopsy and should be credited as part of the E/M service.

*This response is based on the best information available as of 10/17/24.

Evaluation and Management (E/M)

Question:

We had a new patient who came in for evaluation for itchy skin eruptions that had never been treated. He documented a complete history and full skin examination and diagnosed the patient with psoriasis, which was inadequately controlled, and performed an intralesional injection (11900) in the patient’s hand, which was the area of concern.  He found psoriasis on the scalp, hand, and chest and wrote the patient a prescription for Clobetasol ointment and spray.  My question is, can we bill an E/M service with Modifier 25 since he did a complete history and skin exam?

Answer:

The E/M services require a clinically relevant history and examination. This will not determine whether Modifier 25 is supported. What does support a significant separate E/M service is that in addition to the intralesional injection, the physician developed a plan of care that not only included the injection but also prescribed medication to treat the areas. An E/M service based on medical decision-making or time 99203-99205 (new patient) can be reported with modifier 25 in addition to CPT code 11900.

*This response is based on the best information available as of 10/3/24.

E/M service with treatment of Psoriasis

Question:

A new patient came in with an itchy scalp and came into my office today with a flare-up of her psoriasis.  Her psoriasis was diagnosed by another physician about 6 months ago. The psoriasis is worsening in her hand, but her scalp is fairly clear.  She has been using over-the-counter medication, which has not helped.  After a lengthy discussion about her condition, we decided a steroid injection on her palm would be beneficial since her entire palm was covered with scaly patches. I performed an injection on her hand and reported 11900 (intralesional injection).  I also wrote her a prescription for a topical ointment and scalp oil to use when needed.  We also discussed light box treatment, but she wants to try a topical prescription.  My question is can I bill an E/M service with the procedure?  One of my other colleagues told me I could not.

Answer:

Since you are doing more than the evaluation for the injection (11900), yes, you can bill an E/M service.  There is an inherent E/M service included in every procedure, but you counseled the patient, offered alternative treatment options, and prescribed prescription drug medications to the patient.  In this instance, the service does qualify for a significant separately identifiable E/M service with Modifier 25.  Based on the complexity of the problem addressed, which is chronic and not at treatment goal, and you prescribed prescription drug medication, you should report CPT codes 99204-25, 11901 and the J code for the medication injected.

*This response is based on the best information available as of 9/11/24.

Evaluation and Management (E/M)

Question:

We had a new patient who came in for evaluation for itchy skin eruptions that had never been treated. He documented a complete history and full skin examination and diagnosed the patient with psoriasis, which was inadequately controlled, and performed an intralesional injection (11900) in the patient’s hand, which was the area of concern.  He found psoriasis on the scalp, hand, and chest and wrote the patient a prescription for Clobetasol ointment and spray.  My question is, can we bill an E/M service with Modifier 25 since he did a complete history and skin exam? 

Answer:

The E/M services require a clinically relevant history and examination. This will not determine whether Modifier 25 is supported. What does support a significant separate E/M service is that in addition to the intralesional injection, the physician developed a plan of care that not only included the injection but also prescribed medication to treat the areas. An E/M service based on medical decision-making or time 99203-99205 (new patient) can be reported with modifier 25 in addition to CPT code 11900.

*This response is based on the best information available as of 7/11/24.

Diagnosis Coding Excludes 1 Codes

Question:

Our physicians list their diagnosis codes in the Assessment section of their notes. They link the diagnosis codes to the charges in our EHR.   We receive a claims submission edit stating the two diagnosis codes may not be reported together. We review the rules and find the codes have an “Excludes 1” relationship.  Our question is, should we remove the diagnosis code that is listed as the “Excludes 1” from the Assessment section of the note when correcting the claim based on the guidelines.   

Answer:

No.  Great news to hear you are reviewing your claims edit reports timely.  The “Excludes 1” is an ICD-10 coding guideline or a coding rule.  Think of this like an NCCI edit; when CMS has an edit between 2 CPT codes, we do not change the documentation in the operative note, for example, we report the most comprehensive of the 2 CPT codes. The “Excludes 1” guideline is a similar concept—we do not change the documentation; we report the most comprehensive diagnosis code.   

*This response is based on the best information available as of 6/20/24.

Incision and Drainage (I&D)

Question:

My physician wants to know the difference between a simple and complicated I&D.  I cannot find any specific guidance.

Answer:

A simple or single I&D includes drainage of the pus or purulence from the cyst or abscess. The physician leaves the incision open to drain on its own, allowing for healing with normal wound care. A complex I&D includes placing a drainage tube to allow for continuous drainage or packing to facilitate healing. In certain cases, tissue excision, primary closure, and/or Z-plasty may be required. CPT code 10060 is a simple or single I&D and is typically reported when an abscess or cyst is opened with a surgical instrument, allowing the contents to drain. The lesion may be curetted and irrigated. CPT 10061 often involves larger abscesses requiring probing to break up loculations and packing to promote ongoing drainage. 

You should report CPT code 10060 for incision and drainage of a simple or single abscess and CPT 10061 for complex or multiple cysts. Complex or multiple cysts may require surgical closure at a later date. 

*This response is based on the best information available as of 6/6/24.