E/M coded with a procedure - Urgent Care

S Avara CPC

Baton Rouge Local Chapter
Best answers
I'm trying to find some documentation regarding the ability to code E/M with surgical procedures provided in an Urgent Care setting. I've always been under the impression that if a patient comes in for a minor surgical procedure the E/M was included in the procedure it self. Recently, my CEO has questioned this and states that she's talked to several collegues who all bill for E/M and a surgical procedure on the same day for Urgent Care. Does anyone have a link or URL to information stating this is allowed for Urgent care?
I'd like to comment on this, but I always want to get the full picture.

Specifically, give some examples of "minor surgeries." Are we talking skin sutures?

Anyhow, Urgent Care (to my knowledge) is not held to circumstances of coding any differently than other, similar settings. That being said, read the Appendix A descriptor for Mod. 25 in CPT. In many instances it is perfectly appropriate to code and bill both E/M and minor procedures. Coding is very often a case-by-case basis, as you know.

I hope this helps. It'd be too difficult to provide a blanket statement to cover all the variations. Good luck and maybe give us an example we could "consult" on...
Yes, often it is sutures as well as fracture care, I&D, and sometimes removal of impacted ear wax. I know it's a case by case and documentation by documentation situation. But I read this on Medicare's website:

"The following services are included in the global package:
1. Pre-operative visits – Pre-operative visits beginning with the day before surgery for major procedures and the day of surgery for minor procedures."


Do not include the following services in the global surgical package. These services may be
paid separately.
1. The initial consultation or evaluation of the problem by the surgeon to determine the need
for surgery. This only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure."

I know putting a modifier 25 on the E/M code will probably get it paid, but I want to make sure that is correct and within guidelines. The statements above make me doubt that it is correct.
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Well, in the case of the fracture care, since they carry a 90 day global, it is considered "major" and therefore, it would be suitable to add an office visit if documentation substantiates it.

As for the minor procedures, my recommendation would be to query local carriers on the specifics of those guidelines stated. Also, when your physician(s) is/are performing those minor procedures on a Medicare beneficiary, encourage the provider to differentiate between when an E/M is medically necessary (to look for other problems or managing chronic conditions in concordance with the acute problem) and when simply the sutures (for example) are required for management. That would be your key to code assignment. What CMS is describing as Pre-operative sounds to me like commentary on services being rendered to patients/members with a scheduled visit and service. It does not seem to be addressing a case where the patient comes to a provider for initial evaluation (and sometimes treatment) of an emerging problem--like is commonly treated in Urgent Care.

For instance, I've seen providers--when I worked with a payer--billing for Pre-operative admission to the hospital, when it was clear the patient had this prospectively arranged. That is a violation of CPT Surgery section guidelines. That also sounds like the subject of the initial quote in your message.

Also, please note that this guideline would apply only to Medicare patients. Other payers (unless they state the same guidelines, which I doubt) can be coded for both the E/M and procedure--even for minor surgical procedures--as long as the documentation and presenting problem(s) support both services.

In cases where an injury is indicated as a potential or probable third party liability, Medicare does not typically pay, in which case you probably would not need to abide by the stated guidelines--get with your Compliance expert on that one though.

I hope this helps some, but look into what I'm saying about the planned Peri-operative services. That seems more in alignment with what I know of CMS guidelines.
how about in the ER setting,, patients are always coming in with ear aches or wounds and we bill ER visit and the procedure, then the doctor tells them to check with their PCP within the 10 for removal of sutures or packing and they always seem to come back throught the ER because we are a state hospital and it is hard to get an appt. with a physicians, its easier and faster to wait 4-5 hours in the ER... but my question is if a patient comes in with an abscess to the leg and has it I & D in the ER and told to follow up with pcp or Er within 10 days for packing removal, when patients comes in 7 days later for the check up and states a whole other complaint, like sore throat or nasal congestion,, should i bill the appropriate level like 99283 with -24 ?? it is in the post op period but we bill for over 20 different ER physicians, so its not the same physicians,, i was always told that ER had different coding rules than a normal office visit,,
I also work in urgent care. Unless there is a completely separate dx, I do not bill for an E&M with the minor surgical procedure. One of the situations that I do bill an E&M code for is if there is an evaluation for a head injury. I would also double check who is providing the ear wax removal, it must be performed by the physician and the removal must be done with instruments. Search CMS for the ear wax removal code for the requirements for billing this procedure. In my clinic, it is performed by the medical assistants and therefore not billable.
New patient E & M with minor procedure

I code for both an ED and an Urgent care.
Rule # 1 - Is the physician documenting more than just the area that the "surgery" is performed on ?
If yes then need to take into consideration that this is a NEW patient?
Does the patient have comorbidities that may affect the management of the patient ? ie: Diabetes, HTN, Seizure HX, MRSA exposure ?

Medical decision making drives the E & M - if patient is perfectly healthy and has an abscess on lower leg - No RX is prescribed, no other conditions that may affect the outcome of the I & D - then 10060 only. However, if the patient WHO IS NEW TO YOU has any other medical condition that would complicate the procedure, the physician documents an Exp Problem focused exam, and prescribes an antibiotic, the provider is now assessing the risk of the patient to the full treatment, an E & M is a separate service and should be coded with modifier 25

For fracture care - was the patient referred to an ortho within 4-5 days ? If so, definitive treatment has not been done and fracture care should not be coded, only E & M and splint is applicable.
If fracture care is definitive, E & M can be coded with -57 modifier as the patient had to first be diagnosied with the problem ( XRAY ) and prescription medication management is usually applicable.
Keep in mind the global period of "Minor - 10 days" vs Major "90 days"
For sutures - if they come back for removal within 10 days - the suture removal is global and 99024 is the correct code.
If the injury they sustained was a crush, pinch, avulsed, deep etc injury, an expanded problem focused exam may be performed as they may need to check for neurovascular status. Once again, was an expanded problem focused exam performed, and was MDM taken into account by other factors ?

A fall with LAC repair almost always has an E & M, as there needs to be an assessment on whether any other injuries have occurred. A head injury many times requires a CT scan, which is an additional workup to clear the patient of any less obvious injuries
Many factors need to be taken into consideration, with documentation upholding the codes
Hope this helps
Anne S, CPC

Can anyone help we do urgent care billing! My boss ask me how do we bill for staples can not find them in the HCPCS book?
Also what is the code to be used for suture removal?
Can anyone help we do urgent care billing! My boss ask me how do we bill for staples can not find them in the HCPCS book?
Also what is the code to be used for suture removal?

Staples are considered closure, so use the appropriate lac repair code (you don't code separately for suture supplies, same for staples). Suture removal within the global is 99024 with ICD-9 V58.32.

Thank you for Help on sutures removal.
Another question for anyone is anesthesia Local when a I&D is done or MRSA wound. We have been using a 00300 or 00400. The Dr's use the code for Lidocraine code J2001 and Epinephrine J0170 is these the correct codes?
Thanks Billie
Thank you for Help on sutures removal.
Another question for anyone is anesthesia Local when a I&D is done or MRSA wound. We have been using a 00300 or 00400. The Dr's use the code for Lidocraine code J2001 and Epinephrine J0170 is these the correct codes?
Thanks Billie

Local infiltration is part of the surgical package. J2001 as an IV code for lidocaine. It would not be appropriate to report anesthesia codes for local anesthesia. See the surgery guidelines on pg 47 of the CPT Professional edition (just before the surgery codes if you don't have this edition).
suture and anesthesia

I DO agree with NOT reporting the anesthesia. Local anesthesia IS included in the suture and the anesthesia codes 00... are only to be reported by an anesthesiologist and on top of that require a P-status modifier. We usually do not report anything besides the actual suture unless of course there is a E/M visit documented that qualifies to be billed with a 25 modifier.

My question is when a patient has suture done with another PCP not within our group and comes to our office for suture removal during Urgent Care Business hours are we allowed to bill an Urgent care E/M visit with suture removal dx even though it is whitin the 10days global timeframe?
**Please reply.


Marisela Amador CPC
Suture removal by different doctor

If the sutures were placed by a physician who is not in your group practice, then yes, you may code the appropriate level E/M code for the visit to have the sutures removed.

F Tessa Bartels, CPC, CEMC
E/M same day procedure

I agree with Kevin.
You would have to look at it by a case by case.
Our urgent care will use an E/M along with a seperate proceudre being done same day. Their documentation is supportive. Your mod 25 are for procedures 10 days or less and mod 57 are for your global days 30-60-90.