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Minor procedure

  1. #1
    Chula Vista
    Default Minor procedure
    Medical Coding Books
    If a patient comes in with an unknown problem and after examination its determined they need a minor procedure (i.e. wart removal, reduction of elbow) would you bill just the procedure code or would you also use an e/m in addition to the procedure?


  2. #2
    The key is recognizing when your extra work is ?significant? and, therefore, additionally billable. CPT does not define ?significant,? but asking yourself the following questions should lead you to the answer:

    Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
    Could the complaint or problem stand alone as a billable service?
    Is there a different diagnosis for this portion of the visit?
    If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?
    If your answers to these questions are yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as ?A significant, separate E/M service was performed to evaluate ? .?

    I hope this information helps you !!!!
    Amy Pritchett,
    2017-2018 Secretary of Local Mobile AAPC Chapter
    2015-2016 President of Local Mobile AAPC Chapter

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