Pathology/Lab Coding Alert

Question: Sometimes our hematologist sees a patient for the first time; performs an E/M complete with history, exam, and medical decision making; and then decides to perform an unplanned bone marrow biopsy that same visit. May we report both?Answer: You should be able to report both for two reasons:Documentation includes a history, exam, and medical decision making (HEM) separate from the biopsy.The bone marrow biopsy was not the original or preplanned reason for the visit.You should report the biopsy with 38221 (Bone marrow; biopsy, needle, or trocar) and choose the appropriate E/M code based on the documentation. Be sure to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to indicate the separate nature of the service.Helpful hint: CPT's Appendix A explains that a significant and separately identifiable service "is defined [...]