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Primary Care Coding Alert

Reader Question:

Identify Separate E/M From 46600

Published on Mon Sep 15, 2003

Question: When my family physician (FP) performs an anoscopy during an office visit, should I report an E/M service and the procedure?

Nebraska Subscriber Answer: Provided the FP performs a significant, separately identifiable E/M service from the anoscopy, you may report the office visit (99201-99215, Office visit for a new or established patient ...) in addition to the anoscopy (46600, Anoscopy; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Some payers, such as Medicare, may require you to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit.
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