Questions for Dr. Stern

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31. A new patient comes in with a laceration, I still bill the E&M visits with a modifier 57, because we are billing a surgery code on the same day, not a modifier 25, unless we did do something other than the laceration. My thought behind this is that we have not seen this patient before and we are looking at his medical picture for the first time. I'm sure it depends on the documentation right? How much the physician did on that visit and if he addressed any other medical condition?

Good to hear from you. My column from JUCM (on this very subject) may be useful: http://www.jucm.com/2007-jan/Coding.pdf.  Feel free to contact me with further questions or if any questions are not answered by this column.

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David Stern, MD, CPC CEO, Practice Velocity Partner, Physicians Immediate Care Board Member, Urgent Care      Association of America Dr. Stern helped design the patent-pending Practice Velocity template (PiVoT) that is now used in over 240 urgent care centers. He is board certified in internal medicine and served as Chief Resident in Internal Medicine at Pennsylvania State University. Dr. Stern received his medical degree from Jefferson Medical College of Thomas Jefferson University after completing undergraduate studies at Houghton College in Houghton, NY. Dr. Stern serves on the Board of Directors of the Urgent Care Association of America (UCAOA). A Certified Professional Coder, Dr. Stern writes articles and presents at numerous national and regional conferences on topics, including medical charting, emr, medical coding and medical practice management. With additional partners of John Koehler, MD (CEO) and Terry Buzzard, MD (Regional Medical Director), they operate the urgent care consulting firm of National Med Network and the ten clinics (in Illinois and Oklahoma) of Physicians Immediate Care.

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