Corporate

May 14, 2012

Mohs Surgery and Evaluation and Management Services (E/M)

CGS Medical Review is seeing a large volume of E/M services with modifier-25 billed on the same date of service as Mohs surgery. To avoid denials and potential recoupment of payments, the Medical Review Department would like to provide you the following information to consider when billing E/M services on the same date as Mohs surgery.

Modifier-25 indicates a significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service. Appending modifier-25 to an EM service on the same day as Mohs indicates that the physician is providing an E/M service that is not inherent to the Mohs surgery. The payment for the minor procedure (Mohs surgery) includes the evaluation and management services required to perform the procedure. This includes assessing the patient before, during and after the procedure. Some of these services may include; determining readiness or identifying risk factors and/or health conditions that may affect the outcome of the procedure, the patient's tolerance of the procedure and any post-op teaching regarding wound care.

The scenarios below give examples of the correct use of modifier-25 and E/M coding.

  1. A new patient comes in (has not received any professional services from this physician, this practice and this specialty/subspecialty within the practice in the past three years) after being referred by their primary care physician for a malignant lesion. The dermatologist examines the patient, discusses Mohs technique and schedules the procedure for the following week. This is billable as a new patient visit.
  2. The following week the same patient returns and the dermatologist evaluates the patient, reinforces teaching from the previous visit, and performs the Mohs procedure. After closure the physician instructs the patient on wound care and sets a follow-up visit for suture removal. This scenario does not represent a separately identifiable E/M service. All evaluation and management services performed are inherent to the Mohs procedure. If the dermatologist performing the Mohs procedure was asked to evaluate a new lesion or examine an unrelated rash then an E/M and modifier-25 would be appropriate as these services are not related to the Mohs procedure.
  3. A patient presents to the office with a positive pathology report for a lesion. The dermatologist examines the patient, assesses the lesion, provides all the necessary E/M services and performs the Mohs procedure in the same encounter. In this situation it would be appropriate to append mod-25 to an E/M code along with the code for the Mohs procedure. The dermatologist provided all the E/M services with no prior knowledge or evaluation of the lesion and then chose to perform the surgery at the same setting. The E/M component resulted in the Mohs; the E/M was not for the known purpose of providing the procedure.

Using these examples, please review your practice of billing E/M services and minor procedures on the same date of service to assure compliance with correct billing and coding.


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