Coding Corner – Office Billing: Combining E&M and Procedure Codes | Karyn J. Hansen, MD
Scenario 1: Patient aged 73 with a history of endometrial cancer presents for routine surveillance. On exam you noted a 1cm lesion on her vulva concerning for dysplasia. You complete your usual evaluation and management (E&M) for her history of endometrial cancer, as well as complete a vulvar punch biopsy. Can you bill for both an E&M code and a procedure code? Do they need to have different diagnosis codes? Do you need a modifier?
You can bill a minor procedure code (0-10d global days) and an E&M code on the same calendar day in some circumstances. In general, the decision to complete a procedure is included in the procedure code itself, so no additional E&M code is indicated. However, a significant and separate E&M service unrelated to the decision to complete the procedure, or an E&M above and beyond the included evaluation associated with the decision to complete a procedure, can be billed with a modifier -25.
In the above example you could bill a 56605 for the vulvar biopsy with diagnosis of vulvar lesion and a 99211-99215 with a modifier -25 for endometrial cancer with associated evaluation and management.
Scenario 2: Patient aged 66 referred as a new patient after presenting to the emergency department (ED) with postmenopausal bleeding, abdominal pain and distention. ED evaluation including CT abdomen and pelvis demonstrating markedly enlarged uterus with thickened endometrial lining and extensive pelvic lymphadenopathy. In the office you perform extensive E&M services including reviewing history and available records, completing a thorough exam and ordering further imaging and labs. Additionally, you complete an endometrial biopsy to facilitate tissue diagnosis.
You do not have to have a separate diagnosis code; however, your documentation does need to support that the additional E&M was above what is considered part of the decision to complete a procedure itself.
For new patient E&M codes, a modifier -25 is not needed with the procedure code, but the documentation still needs to support E&M services above and beyond what would be included in the decision to complete the procedure.
Karyn J. Hansen, MD, is a Gynecologic Oncologist at Trinity Health of New England in Hartford, CT.