I recently underwent a D and E session with Noridian because they did a post payment review on a number of nail avulsion cases I did. In all cases, it was a 99212 with 11730. They denied the 99212, saying that the E&M was part of the procedure code, which I obviously thought was ludicrous, but they are saying that is their policy. I forgot to ask them 2 questions. 1. Is that also the case with a New Patient E&M? And 2. Does that policy also apply to 11750? Do you guys have answers for those questions? Thank you!
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You underwent actually a SMRC audit with Noridian and those audits need to be taken very seriously. Yes, ALL minor procedures technically have some E/M built into the code. So, whether it is a new patient or established patient if all you are doing is the nail procedure, then that is all you get paid for. The NCCI clearly has the E/M as requiring the Modifier 25 if it is significant and distinct when paired with CPT 11730 or 11750. The question you need to ask yourself, does that patient need that minor procedure that same day? Or does the patient have a cellulitis in the toe in addition to the nail deformity? You have to show CC/HPI having 2 different issues, the examination should be problem focused, the diagnoses should be distinct and then you must document "Medical Management" that is not part of the minor procedure most likely prescribing an antibiotic for the infection to justify that E/M with either CPT 11730 or 11750. This policy is CMS/Medicare, but many private insurances follow CMS guidelines, and it is your responsibility to know.