Pediatric Coding Alert

Question: The CPT® surgery guidelines state that the surgical package includes “one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical).” Our question relates to the term “date.” Some in our office think that the term means that the E/M must be on the “calendar date” of or preceding the procedure to be bundled. Others in our office think that if there’s a related E/M on any day prior to the procedure (maybe earlier the same week) that it is bundled. Which is correct?

Answer: Your colleagues who think the guidelines mean “calendar date,” are correct. That’s why the guidelines state “on the date immediately prior to or on the date of procedure.” A day earlier in the same week is not the “date immediately prior.”

Exception: Remember that if you have a separate, significant E/M service on the same date as the procedure, you can separately code that service using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). For example, the pediatrician may identify a previously undiagnosed problem that requires extra evaluation and documentation.