Wiki Lost with E/M and Procedure Codes

[ElyseGrad11]

I'm missing something important when it comes to coding for E/M services. I'm doing the practice exercises with Practicode right now and am having issues. I'm embarrassed to admit it, but I don't think I ever caught on. How do I know if I need to code a procedure in addition to an E/M visit? I've noticed Labs are usually included in the E/M visit ( if only for interpretation) and X-rays seem to be as well. Please help. I enjoy learning, but if I ever get a job in medical coding this is something I HAVE to know. I feel so stupid.

 

[Amy Pritchett]

You can code any procedure with an E/M visit so long as the physician documents the procedure as separate and identifiable service in the office note. Example (patient comes in with laceration to hand). The physician would document the office note to state the reason for the office visit (level) and then append -25 modifier to the OV code. Then you would code the sutures placed by the physician. Another example would be (the patient came in for a head cold but, also had a wart they wanted removed). You would code for the office visit, append a -25 modifier and then code the wart removal for the same date of service.
Hope this helps