Dermatology Coding Alert

Published on Tue Jan 28, 2014 PDF

Question: The CPT® surgery guidelines state that the surgical package includes “one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical).” Our question relates to the term “date.” Some in our office think that the term means that the E/M must be the “calendar date” of or preceding the procedure to be bundled. Others in our office think that if there’s a related E/M on any day prior to the procedure (maybe earlier the same week) that it is bundled. Which is correct?

Ohio Subscriber

Answer: The folks in the office who think the guidelines mean “calendar date” are correct. That’s why the guidelines state “on the date immediately prior to or on the date of procedure.” A day earlier in the same week is not the “date immediately prior.”

Exception: Remember that if you have a separate, significant E/M service on the same date as the procedure, you can separately code that service using 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). For example, the surgeon may identify a previously undiagnosed problem that requires extra evaluation and documentation.

For major procedures (those with a 90-day global surgical package), the visit when the decision for surgery is made is not included in the global package, even if it happens on the date immediately prior to or on the day of the procedure. Report those E/Ms with modifier 57 (Decision for surgery).