What Does the Decision to Perform a Minor Procedure Really Mean?

• 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.

The procedure code includes typical pre and post work, not a significant and separate evaluation of a condition.

• The NCCI manual does give one clinical example. Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.

In the latest edition of the AMA’s Principles of CPT^® Coding 9^th ed, there is a decision tree regarding using modifier 25. The first question in the tree is “Does the documentation support that’s the patient’s condition required a separate and distinct E/M service, above and beyond the usual preoperative and postoperative services for the procedure?” And, keep in mind that contrary to some payer edits, both CMS and CPT say that the same diagnosis may be used to report the E/M service and the procedure. Although a different diagnosis code is not required, it certainly strengthens the submission.

When reviewing a note, assess whether the documentation shows work that is in addition to the typical pre and post work of the procedure.

Procedures do have pre and post work valued into the procedure.

CITATION

https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf