Evaluation & Management vs. Procedure
Almost every service provided to a patient is either a procedure or an evaluation and management (E&M). When submitting CPT® coding, it is important to differentiate between the two, know which service type was provided, and code appropriately. Stated simply, a procedure typically occurs when something is done to a patient physically. Examples of procedures include cutting, debriding, injecting, and performing an operation. Ulcer debridement is a procedure. An E&M is when a patient is evaluated by a provider and the provider medically manages the patient’s condition. Examples of E&Ms include writing a prescription, making a recommendation, suggesting an over-the-counter product, and referring a patient to another provider. An E&M requires a chief complaint, a history of present illness, an exam, and some form of management as described above. If an encounter with a patient was a procedure, it is not appropriate to submit a CPT code representing an E&M. If an encounter with a patient was an E&M, it is inappropriate to submit a CPT code representing a procedure.
Evaluation, Management & Procedure Submitted At The Same Time
With some exception, providers cannot submit both an E&M and a procedure for the same patient at the same encounter. Chapter I, Section D of the National Correct Coding Initiative Policy Manual For Medicare Services states, “an E&M service is separately reportable on the same date of service as a procedure under limited circumstances.” That limited circumstance is when the E&M is significant and separately identifiable from the procedure.
Significant & Separately Identifiable Evaluation & Management
An E&M is significant and separately identifiable from a procedure performed at the same encounter if there is no overlap in the work associated with the E&M and the work associated with the procedure. Chapter I, Section D of the National Correct Coding Initiative Policy Manual For Medicare Services states a significant and separately identifiable E&M exists if it does not “include any work inherent in the procedure, supervision of others performing the procedure, or time for interpreting the result of the procedure1.” In order to substantiate an E&M that is separately identifiable from a procedure, there cannot be any overlap in work between the E&M and the procedure. This same reference also states, “the decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure, and shall not be reported separately as an E&M service.1” This guidance applies to both new and established patients. The National Correct Coding Initiative Policy Manual For Medicare Services explains this in Chapter I, Section D by stating, “The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure1.”
Documentation
When a significant and separately identifiable E&M and a procedure are both performed, the documentation of the encounter must clearly reflect two separate services with no overlap in work between the E&M and the procedure. The documentation must explain what work was associated with the E&M and separately explain what work was associated with the procedure, with a clear distinction that there was no overlap between the two.
1National Correct Coding Initiative Policy Manual For Medicare Services
Reference – CPT 2021 Professional Edition Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2020 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
Nothing in this document is intended to reflect or guarantee coverage or payment. The existence of a coverage determination does not guarantee payment for the service it describes. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country. Questions regarding coverage and payment by a payer should be directed to that payer. Lehrman Consulting, LLC and Jeffrey Lehrman do not claim responsibility for any consequences or liability attributable to the use of any information, guidance, or advice contained in this document.
