Know When to Bill E/M with a Minor Procedure

Determine when to bundle and when to separately bill services.

Karla M. Hurraw, CPC-A, CCS-P
Many payers bundle an evaluation and management (E/M) service when reported on the same day as a minor surgical procedure. National Correct Coding Initiative (NCCI) edits routinely bundle E/M services with minor surgical procedures, and the Centers for Medicare & Medicaid Services (CMS) policy dictates, “The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package” (Medicare Claims Processing Manual, Chapter 12, Section 40.1.B).
In spite of all of this, providers may (and should) report an E/M service performed on the same day as a minor surgical procedure, as long as medical necessity dictates the need for a separate, significant E/M, and the encounter is supported by documentation and reported with an appropriate modifier.

Interpreting the Rules

A “minor procedure” is any procedure/CPT® code with a zero-day or 10-day global period, as defined by Medicare’s Physician Fee Schedule Relative Value File. Examples of minor procedures include many types of injections, minor integumentary repairs, and endoscopic procedures (e.g., diagnostic colonoscopy).
Per CMS rules, every procedure (whether major or minor) includes an “inherent” E/M component and, as such, you generally may not report a separate E/M service on the same date of service. This rule is repeated throughout CMS policy documents, but is succinctly explained in the Medicare Claims Processing Manual, Chapter 12, Section 40.1.C:
Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.
The “unless” clause is important. It allows you to report (and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is “significant” and “separately identifiable.”
In practical terms, this means:

  1. The medically necessary E/M service must “go beyond” the usual E/M component included as part of the minor procedure.
  2. Documentation must support both the minor procedure and a separate, independent E/M service (e.g., the E/M documentation must “stand alone”). Although it’s not required, best practice is to separate the E/M note from the procedure note.
  3. The appropriate E/M service code must be reported with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.

Unrelated E/M Is Usually Separate

Generally, if the E/M service is unrelated to the minor procedure (i.e., the E/M is for a different concern/complaint), the E/M service may be reported separately.

Example 1

A patient presents to the office for scheduled lesion removal. When the patient arrives, she has a cough, sore throat, and fever, which are evaluated and treated in addition to the scheduled procedure. In this situation, it’s appropriate to bill the E/M service code (supported by documentation) with modifier 25 appended, in addition to the lesion removal.

Example 2

A patient presents to the office for a joint injection, which she receives every three months. During the visit, she mentions that she has been having chest pain and shortness of breath. The provider sends her for a chest X-ray and an electrocardiogram. In this situation, it’s appropriate to bill an E/M in addition to the joint injection.
If the E/M service occurs due to exacerbation of an existing condition, or other change in the patient’s status, that service may be reported separately as long as it’s independently supported by documentation.

Example 3

A patient with known hypertension presents for a screening colonoscopy. While being prepped for the procedure, the nurses note an increase in the patient’s blood pressure. The provider is alerted when he comes to see the patient prior to the procedure, and the patient reveals that his recent home blood pressure checks have also been high. The provider orders an additional medication to lower the patient’s blood pressure prior to the procedure, and instructs him to follow up in the office soon to adjust his medication. This would be a separately billable E/M service on the day of the procedure.

The Visit’s Purpose Can Help You Decide

Even if the E/M service is related to the minor procedure, you still may be able to report it separately. Ask yourself: Did the E/M occur because of the procedure, or was the need to perform a minor procedure determined as a result of a significant (i.e., fully supported by documentation and includes the key elements of history, exam, and medical decision making (MDM)) E/M service? Only in the second case may you report the E/M in addition to the procedure.
The Medicare Claims Processing Manual, Chapter 12, Section 40.1.C, explains:

A visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

Example 4

A patient falls from a skateboard and presents with minor scalp wounds, but with no further injury or symptoms. The reason for the visit is the suture: Without further medical necessity to justify a separate E/M service, no separate E/M service may be billed.
But if the same patient presents with symptoms such as dizziness and nausea, in addition to the scalp wound, the physician will likely provide a more thorough E/M service to determine if the patient has suffered a concussion or other significant injury. The E/M service now drives the visit and may be reportedly separately.

Example 5

The patient presents to receive a pre-scheduled procedure, such as a steroid injection. Whatever E/M service that led to the decision to perform the injection has already occurred, and any related E/M on the date of the injection would be included as part of that minor procedure. Because the minor procedure “drives” the visit, you would not report the E/M service separately.

Initial Consult for a Minor Procedure

Recall that minor procedures (including colonoscopy and endoscopies) have a zero- or 10-day global period and no pre-operative period (other than the day of the procedure). As such, the initial office consultation with the provider to determine the indications and need for the procedure, potential risks, type of sedation, preparation, etc., is a billable service, when medically necessary.

Example 6

A patient presenting to the office for a screening colonoscopy consult has chronic medical conditions and/or takes medication that may affect the risks, preparation method, or type of sedation for the procedure, all of which requires additional consideration and MDM. The patient meets with a provider to discuss these issues, decide whether to proceed, and what precautions will be taken if they proceed. Regardless of when this service is performed (e.g., one or more days before the screening or the day of the screening), you may report it separately, as supported by documentation. By the same logic, a patient presenting to the office for a colonoscopy or endoscopy consultation due to symptoms or a medical condition will require additional decision making, which will substantiate a billable service.
Karla M. Hurraw, CPC-A, CCS-P, holds a degree in Medical Office Administration and is a professional coder with DeKalb Health, an independent community hospital in Auburn, Ind. She is a member of the Fort Wayne, Ind., local chapter.
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

No Responses to “Know When to Bill E/M with a Minor Procedure”

  1. Kim says:

    Really really good info. Thanks

  2. Lisa says:

    What if patient presents to the office for follow up requesting an injection? Patient received injection at last office visit 2 months ago and was told to follow up in 2 months for recheck.

  3. sebby says:

    If patient is told to follow.
    1. To determine effectiveness of injection then a full e/m visit will be performed and should be billed
    If during that follow up hx shows no benefit
    A physical exam is performed on joint. Risk of re injection us considered and then it is decided to re inject this also requiresuggest the 25 modifier.

  4. Sherry says:

    Quick question, the doctor office I work for is a cardiologist when he goes and sees a pt in the hospital for a consultation and then also does a procedure for that same pt on the same day for a first visit in the hospital can he bill for both the procedure and also for the consultation with a 25 modifier appended for the consultation and then the procedure as long as I show that the decision was made based on the initial consultation that the pt needed the procedure done that day?

  5. A Goldman says:

    If the patient returns two weeks after a visit where there was a minor procedure (hemorrhoid banding) and a 25 modifier for anal fissure dx and Rx with NTG and this second visit there is another banding and separate evaluation and treatment for the fissure (NTG ointment and fiber) can there be a 25 modifier for office visit?

  6. ASaiz says:

    You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  7. Jessica G says:

    Would it be appropriate to bill a pap (e/m) with an IUD removal or insertion?

  8. Carol A Gray says:

    If a doctor schedules patient for a cystoscopy for microhematuria but then finds BPH and has a discussion with the patient about having a TURP, would that qualify billing for an E&M at the surgery center?

  9. ALAN HOBER says:

    What modifier we should use with office visit if CPT 67028, J9035 and 66821 performed in same day.

  10. Karen says:

    If a patient comes in and has a routine depo-provera injection every 3 months and provider does see the patient to check on the vaginal spotting, breakthrough bleeding etc. Is it appropriate to report an E&M with a 25 modifier? What about if they the patient has no complaints? In both situations usually provider is performing some type of exam and decision making.
    Any help would be beneficial.

  11. Donna Dean says:

    Patient presents to a practice for first time with complaint of for instance knee pain. Provider reviews the patient’s history of his knee pain, symptoms, possible reasons, does an exam of patient, then decided to do an injection of that knee. No other areas or issues addressed. As mentioned provider does an exam and documents this in his note along with the procedure.
    Since this is a new patient to the provider with an exam does this warrant and E&M with the 25 modifier along with the procedure CPT code charge?

  12. Jaime says:

    Patient comes in for hemorrhoid banding and told to “return if symptoms persist”. Ten days later pt calls and says her symptoms have not improved and is returning for another hemorrhoid banding. It is now past the 10 day global but the need for banding was already established at the initial visit. So does her return procedure require an additional visit to be added? Thanks