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E/M with Biopsy


Wilmington, NC
Best answers
I am hoping someone can answer this question for me. If a Dr. brings a patient in for a FNA of the thyroid and before the actual procedure he discusses lab results, medication changes and other conditions such as Hypothyroidism, Hashimoto's, can we charge a separate E/M code with a mod 25?

Thank you in advance for the help,



True Blue
Modesto, CA
Best answers
The global period of the procedure include pre-operative visits and discussions related to the procedure once the decision for the procedure has been made. Based on your example it would appear the conversation is related to the procedure that will be performed on the thyroid. This does not seem to fit the definition of "separately identifiable."

CMS Notes...

  • The initial evaluation for minor surgical procedures and endoscopies is always included inthe global surgery package.
  • Visits by the same physician on the same day as a minor surgery orendoscopy are included in the global package, unless a significant, separately identifiable serviceis also performed.
  • Modifier 25 is used to bill a separately identifiable E/M service by the same physician on the same day of the procedure.