Actually, you have to look at this in the other direction. Based on what you've indicated, your challenge is going to be how to support that additional E&M code. Payers are just not reimbursing for an E&M on the same day as a procedure. (see underline, my emphasis).
Per CCI:
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is "new" to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.
That having been said, every procedure should document the reason for the procedure, the procedure that's planned, the informed consent, other staff present, anesthesia given, details of the procedure, along with any unusual anatomy, findings, concerns, issues, etc., whether or not specimens were taken and sent to pathology, the patients' tolerance of the procedure, the closure or completion of the procedure, instructions given to patient, and any follow up visits scheduled.
Hope this helps.
