Include Evaluation with Scheduled Procedure

Here is a perplexing problem. When a surgeon meets with a patient an recommends a breast biopsy, we report a consult for this particular visit. On the day of the biopsy procedure, the surgeon will re-examine the patient, answer questions, an so on. The time that is spent prior to the procedure is ten minutes. In a case like this, you will not report a separate E/M with the biopsy.

It is important to remember that all procedures include an inherent E/M component, according to CPT and CMS guidelines. In order to qualify as a separately billable service, any E/M the physician provides must be both signifigant and separately identifiable from the E/M component that has already been included in the procedure.

If the surgeon had provided the initial E/M service and biopsy on the same day, then you would be able to report the E/M service separately, by using modifier 25 (which is significant, separately identifiable evaluation and management service by the physician on the same day of the procedure or service). However, in this case the surgeon has already conducted a full E/M workup before the biopsy, and it has been coded already.

At the time of the biopsy, if the patient in this case has no new complaints, and has no substantial change in her condition (that would prompt a new history, exam, and decision making process) then you should not report a second E/M. You should report only the biopsy for this particular visit.

View all Articles by: Melissa Clark, CCS-P