tatianapotter
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If a provider decides to manage a prescription refill on the same day as an outpatient procedure(lum epidural) is that enough to bill for a separate E/M. Review
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Wiki Separately identifiable E/M
- Thread starter tatianapotter
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Pam Warren
True Blue
It's hard to say without viewing the documentation. Can you tell what the medication is for? Was the condition addressed with any history or exam that would be necessary to support that the provider did more than just say 'do you need refills?' Did the provider indicate the problem, it's status and the need for the continued/changed/updated prescription? Is this documented separately from the procedure note? (doesn't have to be a separate note), but can you identify where the prescription discussion is documented? If the refill is for something other than the procedure performed, and you can identify significant and separately identifiable (the definition for the use of the -25 modifier) documentation, then it may be supported.