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Thread: New Patient E/M and Procedure

  1. #1

    Default New Patient E/M and Procedure

    AAPC: Back to School
    I consider myself to be a pretty astute coder, but I have a coding issue that I need the help of my fellow coders, please....

    I am aware that when a patient presents for a minor surgical procedure with a global period of 0 - 10 days an E/M is generally not reported because the E/M is considered inherent to the procedure unless the E/M is significant or separately identifiable. What about a new patient? When I attended the AAPC conference in June, one of the presenters stated that the CPT guidelines state you can bill an E/M with a procedure if the patient is new with modifier 25 appended. I must have missed this somewhere because I don't ever recall reading this anywhere. Am I missing something here? Is there such a notation in the E/M guidelines? If so, can you point me in that direction?

    Here is the scenario....a patient presents with hearing loss and dizziness. Upon exam the provider determines the patient has bilateral cerumen impaction. The cerumen was removed and the ears were lavaged and curetted. The provider reported code 69210 for the removal (which is correct since the cerumen was removed with instrumentation) and also reported an E/M code with modifier 25. This is a new patient.

    Any thoughts?
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    As long as the assessment is over above and beyound what is needed for the procedure then you are ok. So what else did he exam that is relevant to the patient's condition that is not necessary for the cerumen removal? If you can make a case for it then it should be appropriate.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3


    I don't see anything above and beyond. There is HPI related to the problem and a brief exam of constitutional (general appearance), ENT of course focusing on the EAC/TM, and the lymphatic system (neck nodes). Other than that, nothing unrelated.
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    Hmm but he does not have to exam lymph nodes to remove impacted cerumen. He did that to check for other disease process that might be the cause of the symptoms. If he knew that the impacted cerumen was the problem, then he would have no need to check the lymph nodes. I see an E&M with a 25 modifier.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5


    Thanks so much!
    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P
    Compliance Auditor

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