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Billing Tips and Tricks

Billing procedures with an office visit:

This is one of the most common errors in medical billing. Physicians are either billing for an office visit when they should not, not billing when they should, or not coding it correctly to get it paid.

The six commandments of billing a procedure with an office visit are:

1. If you are seeing a new patient, you can bill both an office visit and a procedure. No exceptions. You must do an evaluation and management on a patient to determine that a patient needs a procedure. Always bill a NEW patient E&M with a procedure code if you did a procedure.

2. You must always use a modifier 25 if you are billing for a procedure and an office visit.

3. If you did an E&M on a patient but decide to have the patient come back for a procedure and nothing else was discussed when you did the procedure, you can NOT bill for another E&M. You already did the medical decision making at the previous visit.

4. If possible, you must use a different diagnosis code for the you E&M and your procedure. This helps substantiate the need for the office visit.

5. Do not have the same six ICD-10 codes on both the procedure and the office visit. What did the procedure treat? What did the office visit treat? Make them different! This is one of the main reasons for denials. You are telling the insurance companies that you are treating the same thing with the office visit and the procedure. This is a red flag that your E&M is not separate and unique from the procedure.

6. Separate the E&M from your procedure:

Ex: Patient presents with cellulitis of the foot. After a thorough exam I prescribed amoxicillin to treat the infection.

Procedure: Patient presents with an ingrown toenail on the right hallux. I performed a nail avulsion

(Obviously, you would go into greater detail)


As you can see you have two different diagnosis cellulitis and ingrown nail. Two different paragraphs. This makes it incredibly easy for an auditor to see that there two separate things being done.


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