Question when can a dx be counted twice in MDM?

[wynonna]

So MD does cautery for epistaxis, which we are billing with cpt 30901.
MD also prescribes mupirocin for same problem-epistaxis.
Can epistaxis count as dx for Rx management? assuming I'm billing 30901 also for epistaxis.

 

[thomas7331]

It would depend on how this is documented, but the writing of post-operative prescriptions is generally considered part of the surgical package. As a general rule, I don't think I would count that toward MDM since your E/M will need a modifier 25 which needs to reflect that the services billed are separately identifiable from the procedure itself.

 

[wynonna]

I understand. There is no global for 30901. Procedure done same day during office visit. I'm thinking you're right, of course that we would need at least 2 separate dx, one for E&M and one for procedure. I think this patient also had nasal polyps.