tci E/M Coding Alert - 2020 Issue Q3

You Be the Coder: Can You Resolve This IUD Removal/Insertion and E/M Scenario?

Question: My ob-gyn either inserts or removes an IUD at the same time as an E/M or preventive visit. Can I report both? Illinois Subscriber Answer: Yes, provided your ob-gyn’s documentation supports using 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). Make sure your physician has his notes in order, because chances are you’ll have to appeal. If the visit qualifies as a preventive service (such as when the patient undergoes an annual visit at the...

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