Wiki E/M with a procedure

[drtmod40]

Question...I know that to bill a E/M with a procedure the visit has to be distinct from procedure. But I question this........New pt come in to see GYN with irregular bleeding. Provider does COMPLETE work up and gives pt options. One of those options being a endo bx. Pt chooses endo bx. and it is performed at same visit. Can you bill new pt E/M with a 25 mod and a endo bx procedure????

 

[bedforak1]

I would say yes, but it's hard to say without the documentation.

 

[CatchTheWind]

I would also say yes: It is billable if the workup is above and beyond the normal work of the endometrial biopsy pre-op.