tci E/M Coding Alert - 2013 Issue 10

Reader Question: Check This Tip for Procedure-Day E/M

Question: Our physician saw a patient in the office and performed wound care. There was limited history, only vital signs taken, and limited medical decision making documented. The doctor wants me to attach modifier 25 and report both the debridement service and the office visit. Is this okay? New Jersey Subscriber Answer: You cannot simply put a modifier on your E/M visit code to get paid. Make sure your E/M is a significant, separately identifiable service from the minor E/M service that payers associate with the procedure. CPT® considers minor procedures to have a very small E/M already included...

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