tci General Surgery Coding Alert - 2016 Issue 2

Compliance: Focus on Diagnoses to Make the Proper E/M Decision

You must document separate services and use modifier 25. A patient walks into the office for a scheduled procedure — but also presents a different problem that your general surgeon must evaluate and manage. Don’t buckle under and lose pay your surgeon deserves when the encounter notes demonstrate two necessary, separate services. Instead, you can bulwark your claims by including spot-on diagnosis codes that catalog the patient’s separate issues. Make Sure Documentation Shows Separate Services Whenever a patient has a pair of unrelated problems that the provider treats, different diagnosis codes aren’t enough: The claim specifics...

To read the full article, sign in and subscribe to tci General Surgery Coding Alert.

Thank you for choosing Find-A-Code, please Sign In to remove ads.