tci Outpatient Facility Coding Alert - 2014 Issue 12

You Be the Coder: Understand How to Count Exam Element Obtained Through a Scope

Question: When reviewing my physician’s notes, how should I count exam elements when they are obtained through a scope, such as 31231 or 31575? Do those elements support the E/M and the scope or just one or the other? I always thought the elements collected via the scope support the procedure only. Alabama Subscriber Answer: If you are reporting an E/M service (99201-99215, Office or other outpatient visit ...) with 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...

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