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ED Coding and Reimbursement Alert

Surgical Procedure Code + E/M Code Can Be Correct Coding

Published on Sat Feb 01, 2003

When can you report both an E/M code and a surgical or procedure code for the same visit? is the million-dollar question. James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa., offers these rules for separately reporting an E/M service in addition to procedure codes. (See other article on this page for more on these distinctions.)

Reporting both a starred procedure and an E/M code is correct if any of the following apply:

the initial E/M documentation indicates an evaluation of the need for the procedure

the visit is postprocedure

the E/M is separately identifiable from the procedure (use modifier -25).

Reporting both a nonstarred procedure and an E/M code is correct if either of the following applies:

the initial E/M documentation indicates significant, separately identifiable content as in enough history and exam to determine the need for the procedure and some exam content beyond body area of complaint. Remember to append modifier -57 (Decision for surgery)

the visit is postprocedure.

Reporting a minor procedure and E/M is correct if any of the following apply:

the visit is during the 10-day global period that is unrelated to the initial procedure

the visit is after 10 days from the date of the initial procedure

the E/M is separately identifiable from the procedure (e.g., an elderly lady has a syncopal episode, falls down, and lacerates her scalp. In this case the repair is a minor procedure, and the syncope justifies a separately identifiable E/M with modifier -25).

Reporting a major procedure and E/M is correct if any of the following apply:

the initial E/M documentation shows significant, separately identifiable content as in enough history and exam to determine the need for procedure and some exam content beyond body area of complaint

the visit is during the 90-day global period that is unrelated to the initial procedure

the visit is after 90 days from the date of the initial procedure.

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