Primary Care Coding Alert

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.