Forum - Questions & Answers

Sep 16th, 2021 - sschwartz 4 

Coding an E/M in place of a minor procedure that will not be paid

If a provider does a procedure such as an I&D 10060 of a Sebaceous cyst L72.3 and there is no symptom to make it medically necessary for say, Medicare...no group 2 code from the LCD list; can an E/M be billed instead of the procedure? We have a provider who often does I&D's of simple Sebaceous cysts which are not inflamed, infected, bleeding etc...and Medicare denies them due to no group 2 or 3 dx to show medical necessity. One of our newer coders wants to bill an E/M with the dx L72.3 then instead of the 10060 so that we don't have a total loss. Is that legal?

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Sep 23rd, 2021 - ChrisW   206  1 

re: Coding an E/M in place of a minor procedure that will not be paid

It would not be appropriate to bill another code in place of the actual procedure. If Medicare does not deem it medically necessary and the patient wants the procedure done anyway, I suggest having the patient sign an ABN. The ABN is informing the patient and also acknowledging the patient is aware the procedure is not considered medically necessary, and they will be responsible for the charges. The ABN is used as a waiver of liability. In this case, it is strongly recommended since the provider is aware and should give a notice to the beneficiary to convey Medicare is not likely to provide coverage. Unless the provider is willing to accept financial liability, the beneficiary should sign an ABN.
Form Instructions Advance Beneficiary Notice of Non-coverage (ABN)

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