Can You Submit Both An E/M Code And A Minor Procedure Code For A New Patient?

If both an evaluation and management (E/M) and a minor procedure are performed at the same encounter, you can and should code both if the (E/M) is separately identifiable from the procedure.

Whether the patient is new or established has no bearing on this. Whether the procedure has a 0-, 10-, or 90-day global period has no bearing on this. The E/M needs to be separately identifiable. This means you need to be able to pull all of the components of performance, documentation and medical necessity related to the E/M out of the procedure, separate the two, and have both still stand on their own as two completely separate services with no overlap.

Here are some examples of when it would be appropriate to code both a new patient E/M and a minor procedure if the documentation supports that a medically necessary, separately identifiable E/M was performed:

• New patient who gets an E/M for tinea pedis and a procedure for toenail debridement
• New patient who gets an E/M for xerosis and a procedure for at-risk callus debridement
• New patient with an ingrown toenail who gets an E/M and a partial nail avulsion (CPT 11730) if the documentation supports an E/M that was separately identifiable from the procedure. If the “plan" section of this note only describes the procedure of a partial nail avulsion, there is no E/M there. However, a separately identifiable E/M would be supported by a robust paragraph explaining the discussion with the patient regarding his or her diagnosis, potential etiologies and treatment options for this diagnosis, potential risks and benefits of different treatment options, potential advantages and disadvantages of different treatment options, how to try to prevent recurrence, the patient’s questions that you answered, and the discussion you had about treatment options.  An operative note of the procedure would be expected to follow this in this example.  

Dr. Lehrman operates Lehrman Consulting, LLC, is a consultant to the American Podiatric Medical Association Health Policy and Practice Department, serves as an expert panelist on Codingline, and is a Certified Professional Coder. Follow him on Twitter at @DrLehrman.

References

1. Medicare Claims Processing Manual, Chapter 12. Available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf . Published Nov. 30, 2018.

2. Increasing your bottom line: using modifier 25 to indicate a separately identifiable E&M service on the same date as another procedure. Novitas Solutions. Available at https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?centerWidth=100%25&contentId=00100352&leftWidth=0%25&rightWidth=0%25&showFooter=false&showHeader=false&_adf.ctrl-state=132gp3idj0_4&_afrLoop=222749921657092#! . Published Jan. 23, 2019.

3. National Correct Coding Initiative/Medically Unlikely Edits: the nuts and bolts of correct coding edits. National Correct Coding Initiative (NCCI). Novitas Solutions. Available at https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00085606&_afrLoop=224303528429265#!%40%40%3F_afrLoop%3D224303528429265%26centerWidth%3D100%2525%26contentId%3D00085606%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D132gp3idj0_33 . Published Nov. 21, 2017.