Billing an E/M on same day as CPT 31231

SE010

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Hello. I am reviewing a chart and trying to determine if the provider should of billed an E/M code along with the nasal endoscopy 31231. The patient had surgery on 6/16/16: coded as 31276, LT, 31255 LT 51, 31267, LT 51, 31287, LT 51. AND on 6/13/16 had 31237, LT. The chart I am reviewing is for DOS 8/25/16, and the patient came in for "post FESS 3". Patient states: Using saline irrigation and reports significant improvement. Provider did a Review of Systems, Exam, Assessment and Plan. I looked up all of the surgery codes noted above, and they do NOT have a global period.

I am thinking I can code the appropriate E/M level along with the 31231?? Some advise?

Thank you.
 

savgrr

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As long as you can show in the documentation the scope is medically necessary and separate from the office visit (hence the -25 on the OV), you can bill the 31231.
 
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