History and Examination requirement for E/M services

Question:

I have been practicing for many years and am confused about the E/M guidelines since the changes were made a few years ago, mainly for my office services 99202-99215.  My coder says I should document an history and examination, but I don’t think this is required anymore.  Am I correct?

Answer:

The evaluation and management service levels are no longer determined by history and examination but are based on medical-decision making or Time except for emergency department visit codes (99281-99285), which do not contain a time component. However, a clinically relevant history and examination are required based on the practitioner’s clinical judgment. It is essential to tell the “story” of the patient’s clinical picture in the documentation. The history and examination support the medical necessity for the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical practitioners.

*This response is based on the best information available as of 1/2/25.

Which Modifier Should I Use?

Question:

I need some help with using Modifiers. I work for a Mohs surgeon, and he frequently performs Mohs, and the patient comes back differently for a flap or graft. They usually come back within a week. What modifier should I add to the repair when the patient returns?

Answer:

Mohs Micrographic surgery has a global period of “0” days. That means if the patient comes back for the repair on a different date, no modifier is required. 

*This response is based on the best information available as of 12/19/24.

Billing an E/M Service after Mohs when a repair is indicated

Question:

Our Mohs surgeons sometimes perform an adjacent tissue transfer or a flap after Mohs surgery. Since they decided to do the flap after Mohs, they want to bill an E/M service with Modifier 57. I don’t think this is correct. Can you help clarify?

Answer:

The E/M service should not be reported after Mohs surgery when a decision is made for a repair, flap, or graft.  Even though a flap has a 90-day global period, the surgical decision was made to perform Mohs, the primary procedure.  The intent of the E/M with Modifier 57 for a procedure with a 90 global period is when the initial decision is made to perform the primary procedure.  The repair is secondary; therefore, billing an E/M service is inappropriate.  The discussion and recommendation for the repair is part of the pre-service work for the repair and the E/M service is inherent to the procedure. 

CMS Global Surgery Workbook says: “When the decision to perform the minor procedure comes immediately before a major procedure or service, we consider it a routine pre-operative service and you can’t bill a visit or consultation with the procedure. MACs may not pay for an E/M service billed with CPT modifier –57 if it’s provided on the day of, or the day before, a procedure with a 000- or 010-day global surgical period. “

Source: https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf

*This response is based on the best information available as of 12/5/24.

Adjacent Tissue Transfer

Question:

We are having some controversy in the office.  Many of our physicians state the sq cm size of the primary and secondary defect combined is enough to support an Adjacent Tissue Transfer.  Can you help?

Answer:

To properly code for an Adjacent Tissue Transfer (ATT), you must document the site of the ATT, the size of the primary defect, the size of the secondary defect, and the total square centimeter size (add the size of the primary defect, the secondary defect and report the total size

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

Soft Tissue Tumors

Question:

I just started coding for Dermatology practice. I need some clarity on soft tissue tumor excisions. My physicians are telling me that when a soft tissue tumor excision is performed, the procedure includes all repairs, including a flap repair. If the physician removes a soft tissue tumor and does a flap on the same day, can I report the flap separately?

Answer:

All soft tissue tumor CPT codes 21011-21016 for the head, face, or scalp and 21552-21558 (neck and thorax) are reported based on anatomic location and centimeter size. These codes include direct closure (e.g., simple, intermediate, and complex repair). However, other types of closure may be separately reported, such as adjacent tissue transfer, split-thickness/full-thickness graft, muscle flap, etc., in addition to the soft tissue tumor excision.

*This response is based on the best information available as of 11/14/24.

XTRAC

Question:

Our practice is considering using XTRAC for patients with psoriasis. Before we purchase the laser, we want to make sure we get paid. Is there a CPT code for XTRAC?

Answer:

There is a CPT code for XTRAC, an excimer laser treatment for psoriasis. There are actually three codes: 96920, 96921, and 96922. The codes are selected by square centimeter size. CPT 96920 is reported for 250 square centimeters or less, 96921 when the total area treated is 250 to 500 square centimeters, and 96922 for treated areas over 500 square centimeters. The side of the treated area must be included for CPT codes that are reported based on centimeter or square cm size documentation.

*This response is based on the best information available as of 10/31/24.