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OP Procedure E & M Code

  1. Default OP Procedure E & M Code
    Medical Coding Books
    We have a physician in the hospital (Critical Access Hospital) who is seeing patients to do colonoscopies and EGD's. Prior to doing the procedure, he is setting down with the patient and doing a History & Physical. How should I code his time spent doing the History & Physical properly? Is it considered part of the procedure code or can I code it separately.

  2. #2
    Milwaukee WI
    Default Part of procedure
    If the patient was scheduled for the procedure, then the short pre-procedure E/M is bundled into the service.

    If the patient presented in the ER with a problem and your physician was called to evaluate and as a result decided the patient needed the procedure right away, you could charge the E/M separately. (And you'd append the appropriate modifier to the E/M code.)

    F Tessa Bartels, CPC, CEMC

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