Global Surgery Guidelines for Minor Procedures
Medicare allows payment for an E/M service performed on the same day as a surgical procedure, if all requirements are met. The term surgery or service includes therapeutic injections and wound repairs. The additional E/M service must be separately identifiable from the surgical procedure and require significant effort above and beyond the usual pre and postoperative service routinely required for the procedure. The term separately identifiable means an additional service is not part of the surgery or procedure. Medical records should document the E/M service to such an extent that, upon review, the extra effort may be readily identifiable. The E/M service must require additional history, exam, knowledge, skill, work time, and risk, above and beyond what is usually required for the surgery or procedure. Note: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed. Modifier -25 is used to bill a separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure. CMS Global Surgery Fact Sheet ICN 907166 February 2012
