TEST YOUR SKILLS

Guidelines for billing an E/M visit and a procedure on the same date of service include:

Answer: c

It is appropriate to bill both the E/M visit and a procedure on the same day when the decision to perform the procedure was decided during the same encounter. The diagnosis code does not have to be different, but in some cases the diagnosis for the procedure may be different from that of the visit. The modifier ­25 needs to be used with the E/M visit code to designate that the visit was a separate, identifiable service from the procedure.

If the decision to do a procedure was made at a previous encounter and the medical record documentation states the patient is to return for the selected procedure, then on the date the procedure is performed, only the procedure should be billed.

Example: 1st encounter states "patient to return in one week for xyz procedure". 2nd encounter, approximately a week later states "patient is in for xyz procedure today", then only the procedure would be billed for the 2nd encounter.

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