General Surgery Coding Alert

Question: Patients frequently are referred to our office for evaluation of skin lesions. Occasionally, these lesions are removed or biopsied using a punch biopsy. Can we bill an E/M code in addition to a procedural code on the same day?

New York Subscriber

Answer: You may, in certain circumstances, report both an evaluation and management (E/M) code and a procedural code, says C.J. Wolf, MD, CPC, senior coding consultant at Intermountain Health Care, a multispecialty practice in Salt Lake City. When it is appropriate, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to the E/M code.

If the physician knows that the patient was coming in only for a lesion biopsy or excision and a separate evaluation did not take place, reporting both an E/M and procedure code is inappropriate. If the patient presented with a chief complaint of a strange sore, however, and the physician performed the appropriate history, physical exam, and medical decision-making, all of which are beyond the usual preoperative and postoperative care associated with the procedure, it would be appropriate to report both a procedure code and an E/M code.

The diagnosis code used for the procedure may be the same as the diagnosis code chosen for the E/M.

Note: The CPT manual notwithstanding, some private carriers still demand two diagnoses in such situations.