Evaluation and Management (E/M)

Question:

We had a new patient who came in for evaluation for itchy skin eruptions that had never been treated. He documented a complete history and full skin examination and diagnosed the patient with psoriasis, which was inadequately controlled, and performed an intralesional injection (11900) in the patient’s hand, which was the area of concern.  He found psoriasis on the scalp, hand, and chest and wrote the patient a prescription for Clobetasol ointment and spray.  My question is, can we bill an E/M service with Modifier 25 since he did a complete history and skin exam? 

Answer:

The E/M services require a clinically relevant history and examination. This will not determine whether Modifier 25 is supported. What does support a significant separate E/M service is that in addition to the intralesional injection, the physician developed a plan of care that not only included the injection but also prescribed medication to treat the areas. An E/M service based on medical decision-making or time 99203-99205 (new patient) can be reported with modifier 25 in addition to CPT code 11900.

*This response is based on the best information available as of 7/11/24.