The usage of an E&M and a procedure in the facility setting to justify the 25 modifier is exactly the same as in the physician setting. Meaning if you can provide documentation to support that the procedure was not a scheduled procedure, if you can provide documentation to support that the resources were above and beyond what the procedure requires for completion. Every procedure code includes in the work performed any services necessary to provide the procedure, such as a brief assessment and taking vitals. So what is documented in excess, and as I stated earlier was the procedure already scheduled.
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