Same-day E/M and Office Procedure: Yes, You Can!

Documentation and proper modifier 25 application is essential.

By Abraham (Nick) Morse, MD, MBA

Providers generally learn from their billing and coding staff that reimbursement for office procedures includes the immediate pre- and post-procedure management of the patient. In my experience, providers sometimes “over learn” this lesson, and conclude that it is never possible to receive separate reimbursement for an evaluation and management (E/M) service and an office procedure at the same encounter.

Evaluation and Management – CEMC

To capture all appropriate revenue, it is important to know what is included in the global package for office-based and surgical procedures, and understand when an E/M service and an office procedural service can be billed in the same encounter, with appropriate documentation.

What’s Included in the Global Package

The American Medical Association’s (AMA’s) 2012 CPT® Professional Edition codebook defines the following as “always included” in the global fee for a surgery or procedure:

  • Subsequent to the decision for surgery (procedure), one related E/M encounter on the date immediately prior to, or on the date of, the procedure
  • Immediate postoperative (post-procedure) care, including talking with the family and other physicians

Regarding diagnostic procedures, CPT® further specifies, “Follow-up care for diagnostic procedures includes only that care related to recovery from the diagnostic procedure itself. Care of the condition for which the diagnostic procedure was performed or of other co-existing conditions is not included.” [emphasis added]

Medicare’s definition of the global package is broader than the AMA’s, but clearly states, “Services not included in the global surgical package are as follows:

  • The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery [procedure];
  • Treatment for the underlying condition or an added course of treatment, which is not part of normal recovery from surgery;
  • Diagnostic tests and procedures, including diagnostic radiological procedures.”

Common Scenarios for Separate Services

With a clearer understanding of what is meant by “global package” (and what counts as counseling for E/M services), you can identify two common scenarios where billing for an E/M at the same encounter as a procedure is legitimate—provided there is the appropriate documentation in the medical record.

1.  A related E/M service provided prior to an unplanned procedure may be billed separately.

The procedure must not have been the reason for the visit, and documentation must reflect the medical decision making (MDM) based on the evaluation undertaken at that visit that preceded the recommendation of a specific procedure. Documenting the options offered to the patient (with the eventual choice of the performed procedure) strongly supports billing an E/M and procedure together.

Example: A postmenopausal woman is seen for an urgently scheduled appointment in her gynecologist’s office because she noticed blood in her underwear. Upon examination, the source of the blood appears to be the cervix. The gynecologist offers the patient a choice of scheduling a pelvic ultrasound or undergoing immediate endometrial biopsy (EMBx). The patient chooses an immediate EMBx.

The proper coding in this example is 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) and the appropriate level E/M service (e.g., 99212-99215, “Office or other outpatient visit for the evaluation and management of an established patient”) with modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service appended.

Note that it is not unexpected that an EMBx was going to be performed, but the documentation supports that it was not planned prior to the E/M service.

2.  “Counseling and coordination of care” that take place immediately after a diagnostic procedure may qualify as a separate E/M service.

Remember, the global payment for any procedure includes pre-procedure explanation and preparation, as well as post-procedure instructions, restrictions, and precautions, plus information about what to expect during the recovery period. It does not include the MDM that follows as a result of the procedure performed. That work is separate, and if documented clearly, separately billable.

Documentation should be specific as to the time involved and the content of the counseling. In addition to providing a reasonable narrative of “counseling and coordination of care” that follows the interpretation of the results of an office procedure, it is important to include in the documentation a statement such as, “Exclusive of the procedure, greater than 50 percent of the visit was spent in counseling and coordination of care. Total visit time: 15 minutes.”

Example: A patient undergoes cystoscopy in the physician office because of bladder pain syndrome. Multiple fields of glomerulations are noted. Immediately following the procedure, the physician counsels the patient on the pathophysiology of interstitial cystitis (IC), as well as possible treatment options. After discussion, the patient chooses to start Elmiron® (Pentosan polysulfate). She will follow up in six weeks.

In this case, proper coding is 52000 Cystourethroscopy (separate procedure) and the appropriate E/M service level (e.g., 9921x) with modifier 25 appended. Documentation must substantiate that the E/M service is both significant and separately identifiable from the E/M component included in the payment for 52000.

Careful and Deliberate Documentation Is Essential

Although the immediate pre-procedure and post-procedure care and counseling of the patient is included in the global fee for an office procedure, other related E/M work is not. The immediately preceding evaluation that leads to the recommendation of an office procedure can be billed on the same day as the procedure itself. Similarly, counseling and MDM that arise from the results of a procedure may take place immediately following it and are separately billable. In both cases, careful and deliberate documentation to separate the work embodied in the two CPT® codes is essential.


Define Counseling

An important component of E/M services is “counseling,” which the 2012 CPT® codebook describes as “a discussion with a patient and/or family concerning one or more of the following areas:

  • Diagnostic results impressions and/or recommended diagnostic studies
  • Prognosis
  • Risks and benefits of management/treatment options
  • Instructions for management/treatment and/or follow-up
  • Importance of compliance with chosen management/treatment options
  • Risk factor reduction
  • Patient and family education”

Note that these services are often the content of conversations occurring after office diagnostic procedures.


Same-session Preventive E/M and Procedure May Prove Problematic

Although the same rules apply, in my experience—and the experience of my billing staff—it is more difficult to obtain separate payment for an E/M service and a same-encounter procedure if the E/M is a preventive service (associated with a V code) rather than a problem-based visit coded with an ICD-9-CM problem diagnosis.


Abraham (Nick) Morse, MD, MBA, is a practicing physician in the division of urogynecology at Brigham and Women’s Hospital, and an assistant professor at Harvard Medical School in Boston, Mass. He has been a student of billing, coding, ambulatory practice, and revenue cycle management for more than 10 years.



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