# Surgical/E&M codes



## MHira (Dec 28, 2017)

Is it ok to send both E/M and surgical service together if no separate identifiable non-surgical service  is given at the time of service?
Is it per payer contract, which can allows both together(E/M and Surgical codes) or E/M code can supersede Surgical code even though it is truly surgical visit? 

In my understanding so far
Visits by the same physician on the same day as a minor surgery are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
•	The “unless” clause is important. It allows you to report(and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is significant” and “separately identifiable”  
•	In practical terms, this means: The medically necessary E/M service must “go beyond” the usual E/M component included as part of the minor procedure.
•	Documentation must support both minor procedure and separate, independent E/M service(e.g., the E/M documentation must “stand alone”). Although it's not required, best practice is to separate E/M note from the procedure note. 

Is it considered noncompliant if both surgical and E/M codes goes together without documentation support for both being done at time of service?

Thanks and appreciate knowledge support!


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## csperoni (Dec 29, 2017)

I'm a bit confused by your post.  You seem to understand that you should bill E&M same day as procedure ONLY IF there is a "significant, separately identifiable" service.  But then ask if you should bill it if there is no documentation to support it??  The answer for coders should always be if there is no documentation to support it, DO NOT CODE/BILL for it.


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## MHira (Jan 2, 2018)

cms@islandoncology.com said:


> I'm a bit confused by your post.  You seem to understand that you should bill E&M same day as procedure ONLY IF there is a "significant, separately identifiable" service.  But then ask if you should bill it if there is no documentation to support it??  The answer for coders should always be if there is no documentation to support it, DO NOT CODE/BILL for it.



Thanks and appreciate your reply. I'm sorry that I didn't explain the situation. 
With one example below-
Patient has come with laceration/injury/open wound and provider is entering fields for HISTORY(HPI, ROS, medical/personal history), EXAM(explanation of problem area along with other general body systems)and MDM of Procedure done- laceration repair with sutures and plan to come back for removal of sutures within given days. The diagnosis is of laceration/injury/open wound repair. 

In an EMR it is coming along with E/M code and procedure code. As there is possibility of nonsurgical reason along with E/M if that is the reason. But in the above situation, the main reason of visit is laceration and since procedure code has inherent component of E/M, we should not charge E/m charge along. My question is with all above complete fields of History, Exam and MDM along with procedure description does it qualifies for separate E/m code along with procedure code. 
In my opinion this visit doesn't qualify for separate E/M along with procedure code and my fight is to stick to NO  with most non-coders/management.   
This is one example and can be given under other surgical procedures of I&D, burn debridement, Foreign body removal etc.

I just want to verify if in above situation, if it is ok or not ok to charge both codes(E/m and procedure)


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## mitchellde (Jan 2, 2018)

MHira said:


> Thanks and appreciate your reply. I'm sorry that I didn't explain the situation.
> With one example below-
> Patient has come with laceration/injury/open wound and provider is entering fields for HISTORY(HPI, ROS, medical/personal history), EXAM(explanation of problem area along with other general body systems)and MDM of Procedure done- laceration repair with sutures and plan to come back for removal of sutures within given days. The diagnosis is of laceration/injury/open wound repair.
> 
> ...



if the documentation does not support a significant and separately identifiable E&M then you do not submit the code.  The sample you have submitted does not support a separate E&M.


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## MHira (Jan 2, 2018)

mitchellde said:


> if the documentation does not support a significant and separately identifiable E&M then you do not submit the code.  The sample you have submitted does not support a separate E&M.



Thanks for your reply!


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## cbwalking (Jan 4, 2018)

I'm wondering what the provider actually documented.  If the laceration was deep and it was necessary to evaluate for nerve damage wouldn't that be above and beyond laceration repair?

CCI Edits:
Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. 
    **However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.**


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