Wiki E/M and Procedure same day, New patient


Hawthorne, FL
Best answers
If a patient is referred to us for Epistaxis R04.0 and we have never seen them before, we do the E&M and it is decided that the patient needs a scope.

Can we bill a new patient visit and a scope on the same day 99204 with a 25 modifier 31231 Nasal Endoscopy?
Since the patient did not come in specifically for the scope and the decision was made during the encounter a separate E&M can be billed. The separate E&M should be clearly documented and medically necessary. Was the nose also packed? Jim

No the nose was not packed.

I have another scenario also, if you could help.
A new patient is referred to our office for acute pharyngitis, unspecified. The doctor examines the patient and then indicates that a laryngoscopy was done after a mirror exam was attempted but do to limited visualization with the mirror it was felt that a complete exam was warranted and did the laryngoscopy. Diagnosis is J38.4 Edema, Laryngeal and K21.9 Gastro-Esophageal Reflux Disease.

Would it be appropriate to bill 99204 with a 25 Modifier and 31575?

Thank you for all of your help.