All surgical procedures require SOME evaluation. If all that is done is what would normally be done in prep for the procedure, then no "separately identifiable" E/M service has occurred and you wouldn't code any E/M in addition to the procedure.
IF a separately identifiable E/M was performed, you would code it with the -25 modifier.
Let's say, for example, that a patient is sent to you for consultation regarding a mole. You've never seen this patient before. You take a history, perform an exam, make your assessment and plan. Let's say that your plan is to perform a biopsy and you schedule the patient to return in two days time for that procedure. You would code the appropriate consult code for today's visit (no modifier needed). Two days from now, you'd code the biopsy with no E/M (even though you'd probably still perform some basic exam and history before proceding).
Now let's take that same scenario, but you are able to perform the biopsy right away in the office on the same date as the initial consult. You would code the consult with a -25 modifier, and the biopsy.
Hope this makes sense.
F Tessa Bartels, CPC, CPC-E/M
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