Primary Care Coding Alert

Question: If a patient presents for a Medicare Wellness Visit (MWV) and the provider notices acute otis media (AOM) and prescribes an antibiotic, does that support a separate evaluation and management (E/M) service?

Oregon Subscriber

Answer: Yes, this scenario likely supports a separate E/M service, provided the physician adequately documents the discovery, evaluation, and management of the AOM and that documentation demonstrates that the work done was separate from and over and above the work involved in the wellness visit. The documentation needs to include specific details of all parts of the E/M, making sure to include that they wrote a prescription.

Therefore, assuming the documentation supports it, in addition to the code for the MWV, you will report a separate E/M code and append 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) to that separate E/M code to indicate a significant, separately identifiable E/M service on the same day as the MWV.