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General Surgery Coding Alert

Reader Question:

Check Modifier 25 Opportunity

Question: Our surgeon examined a patient in the office who had a head laceration. After the exam, the surgeon sutured the wound. Can we report an E/M code in addition to the repair code?

Nebraska Subscriber

Answer: From what you’ve described, you should not separately report an E/M code along with the repair code.

Remember that every procedure has a small amount of E/M built into it, so you won’t typically bill a separate E/M with an office procedure.

Exception: If the surgeon meets the following criteria, you may report a separate E/M along with a procedure code:

  • The surgeon’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the procedure
  • The E/M service occurs for the same patient on the same calendar day as the procedure
  • You’re reporting an E/M service using a code from the range 99201 through 99499.

In those cases, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code.

For instance: If your surgeon had documented performing a concussion clearance in addition to the head laceration repair, you could report an appropriate E/M code using modifier 25 along with the code for the repair.