• This article is updated with CPT’s March 2023 document, “Reporting CPT Modifier 25.” (citation at the end of the article)
• The CPT article adds specificity to what is included in typical pre and post work, which will make it more difficult to report both a procedure and an E/M service for some encounters.

According to the AMA document, do not bill an E/M service for this work, which is considered the usual pre and post-procedure work:

• Review of the patient’s relevant past medical history,
• Assessment of the problem area to be treated by surgical or other service,
• Formulation and explanation of the clinical diagnosis,
• Review and explanation of the procedure to the patient, family, or caregiver,
• Discussion of alternative treatments or diagnostic options,
• Obtaining informed consent,
• Providing postoperative care instructions,
• Discussion of any further treatment and follow up after the procedure.