# How to Audit an E&M with Procedure



## sjsantjer (Oct 6, 2011)

If a minor procedure is done along with a seperatelly identifiable E&M, two different diagnosis, do you count the bullets of the minor procedure HPI, Exam and MDM, when calculating the E&M? I know that each procedure has some E&M built in, but when your doing an audit what counts?? Is there a book with good examples of E&M audits when procedures are done? Thanks


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## FTessaBartels (Oct 7, 2011)

*E/M documentation stands alone*

No, you cannot count HPI or any other elements from the PROCEDURE note in determining the appropriate level of service for the E/M.  The E/M documentation needs to stand alone (not to say it can't all be combined in one note ... though this is messy ... but has to be clearly separate from the procedure.)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## sjsantjer (Oct 18, 2011)

*Audit E&M with minor procedure.*

Thanks for the clarification. Does any of the Auditing books have good examples of how to audit E&M's with minor procedures. I need examples for the doctor. I work in dermatology and every other patient has an E&M with a minor procedure.


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## FTessaBartels (Oct 20, 2011)

*Just the basics*

If the patient presents to HAVE a lesion REMOVED ... you code ONLY the procedure; the RVUs of the procedure and reimbursement of the procedure INCLUDE the basic E/M.

If the patient presents to have a lesion EVALUATED ...you code the E/M.   IF as a result of that evaluation the physician decides to perform a procedure, even if done that same day, you may also code the procedure. You will need the appropriate modifier on your E/M service. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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