Wiki e&m office with procedure on the same day

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Stacyharter98

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Could anyone tell me if it's mandatory that if you are billing an e&m w/procedure on the same day in the office, if the procedure done needs to be in a separate paragraph? If so, is there somewhere on the CMS website that I can get this rule?
 
It doesn't have to be in a separate paragraph. As long as you have documentation to support the services billed, you are good to go.
 
As far as I know, it doesn't need to be in a separate paragraph, as long as the procedure is documented in the chart as a separate, identifiable service, you are able to bill for both (with the appriopriate modifer on your E/M).
 
Planned vs Performed

Just a word of caution ... I frequently see documentation (for an ER visit as an example) that includes in the Asseessment and Plan "we will suture laceration (or whatever minor procedure they are doing immediately)."

This does NOT qualify as proper documentation of a procedure. Saying you WILL do something is not the same as documenting you DID something.

On the other hand if the same sentence read "2 cm laceration on back of right hand, closed with simple repair using Dermabond," that would tell me exactly what was done and I would code CPT 12001 along with the appropriately documented ER visit (with -25 modifier).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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