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Scheduled procedure billed with E/M

Tierni Posted Wed 08th of February, 2017 16:45:19 PM
I have a provider that is consistently appending a 99215 when a patient comes in for a scheduled procedure. The CC is "colposcopy". First line of HPI is "53yo G1P1 presenting for scheduled colposcopy for abnormal pap smear finding" I have audited the claim and the level for an e/m is 3. Can a E/M service be billed with a scheduled procedure?
SuperCoder Answered Thu 09th of February, 2017 01:37:57 AM



According to CPT, both the Evaluation and Management Service (E/M) and the procedure should be reported if a patient's condition requires a "significant, separately identifiable" E/M service. "Significant" implies that the E/M service required some level of history-taking, examination, and/or medical decision-making. "Separately identifiable" means the visit is distinct from the procedure (colposcopy for abnormal Pap smear finding). In other words, the E/M service should be above and beyond the usual care associated with the procedure.  



Use modifier 25 when the E/M service is separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered.



In your given scenario, the E/M visit was for a scheduled procedure, hence, separate E/M service cannot be billed.


The 99215 represents the highest level of care for established patients being seen in the office.

The documentation for this encounter requires TWO out of THREE of the following :

1)  Comprehensive History
2)  Comprehensive Exam
3)  High Complexity Medical Decision Making

Or 40 minutes spent face-to-face with the patient if coding based on time.  The appropriate documentation must be included.


Kindly check for the E/M components to determine the level of care.

For level 3 E/M service, appropriate code would be 99213.


Thank you!




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