Established patient comes to the office complaining of migraine headaches, Physician performs an expanded problem focused history and exam. The Physician's medical decision making is of low complexity. During the office visit, the Physician also removes a benign 0.5 cm lesion from the back of the patient's left hand. My code is 99213-57/11420. I made this choice because the decision based on the exam and history, but the Physician also made a decision to remove lesion not recorded in the original Chief Complaint. Am I correct, or should I remove the 57 modifier?
Physician removes a foreign body from the anterior chamber of the patient's eye. An allergy statement in the patient's medical records indicates that the patient is allergic to local anesthesia, as a result general anesthesia is administered - my code 99222/65235-47, because the Physician administered the anesthesia himself, there is no mention of anesthesia services administered by an AA, MDA or CRNA. Did I use modifier 47 correctly?
It would be inappropriate to append modifier 57 to an E&M code that was done the same day and was a minor surgery with no global. Modifier 57 should only be used on a procedure that has a 90 day global period. I would suggest removing the modifier 57 fromt he E&M code.
Using modifier 47 would be correct in this case. Not for the anesthesia, but for the Physician providing the anesthesia. Modifier 47 would not be used when the anesthesiologist administers the anesthesia. Due to the anesthesia being considered inclusive with the surgery, the modifier is considered informational only.