Wiki Modifier 25 , E/M with minor procedure

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LAT93

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I thought I would get people's thoughts on adding an E/M to a minor procedure (cysto). I keep going back and forth on what would be correct.

Pt comes in for scheduled Cysto due to BPH luts, they are able to determine severity of enlargement and after the procedure they discuss possible options. RX vs Urolift (minor procedure/0-day global) vs TURP (major procedure/90-day global).

Would you give POEM? Why or why not? - I think no since those options are the "course of action" depending on what pt wants. While they are significant they are not separate

If patient had cysto due to luts (lower urinary tract symptoms) and then was diagnosed with BPH which resulted in the discussion and decision for any of the 3 options mentioned above, then I could see giving provider the POEM.

or does it all boil down to the documentation that the provider gives?

Thank you in advance!
 
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The AMA has these very helpful resources on modifier 25 and what is included in the pre- and post-operative services:

Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:
— Review of patient’s relevant past medical history,
— Assessment of the problem area to be treated by surgical or other service,
— Formulation and explanation of the clinical diagnosis,
— Review and explanation of the procedure to the patient, family, or caregiver,
— Discussion of alternative treatments or diagnostic options,
— Obtaining informed consent,
— Providing postoperative care instructions,
— Discussion of any further treatment and follow-up after the procedure.

 
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Queizati said:
The AMA has these very helpful resources on modifier 25 and what is included in the pre- and post-operative services:

Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:
— Review of patient’s relevant past medical history,
— Assessment of the problem area to be treated by surgical or other service,
— Formulation and explanation of the clinical diagnosis,
— Review and explanation of the procedure to the patient, family, or caregiver,
— Discussion of alternative treatments or diagnostic options,
— Obtaining informed consent,
— Providing postoperative care instructions,
— Discussion of any further treatment and follow-up after the procedure.

Click to expand...
I will look into this, thank you!
 
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Queizati said:
The AMA has these very helpful resources on modifier 25 and what is included in the pre- and post-operative services:

Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:
— Review of patient’s relevant past medical history,
— Assessment of the problem area to be treated by surgical or other service,
— Formulation and explanation of the clinical diagnosis,
— Review and explanation of the procedure to the patient, family, or caregiver,
— Discussion of alternative treatments or diagnostic options,
— Obtaining informed consent,
— Providing postoperative care instructions,
— Discussion of any further treatment and follow-up after the procedure.

Click to expand...
regarding the bullet point for "discussion of alternative treatments or diagnostic options. Would that include the decision for surgery? That's my confusion.
 
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