On the same day as a minor office procedure, the physician also evaluates a significant, separately identifiable problem unrelated to the usual pre-procedure work. How should professional coding treat the E/M?
Select an answer to reveal the explanation.
Short Explanation
The little look-over that comes with a procedure is already in the procedure’s price of admission. A real second problem that needs its own brainpower can still get an E/M—with the right modifier and a note that proves it was separate.
Full Explanation
CPT and payer rules generally include the usual pre-procedure evaluation and immediate post-procedure care in the procedural service. A significant, separately identifiable E/M service above and beyond that usual work may be reported with the appropriate modifier (commonly 25 for minor procedures) when documentation supports it. Always bundling, always separating without modifier support, or dropping the procedure are incorrect extremes. The note should clearly distinguish the separate E/M work from the procedure-related assessment.