E/M Services Code and Procedure Code
If discussion of contraceptive options takes place during the same encounter as a procedure, such as insertion of a contraceptive implant or IUD, it may or may not be appropriate to report both an E/M services code and the procedure code:
- If the clinician and patient discuss a number of contraceptive options, decide on a method, and then an implant or IUD is inserted during the visit, an E/M service may be reported, depending on the documentation.
- If the patient comes into the ofﬁce and states, “I want an IUD,” followed by a brief discussion of the beneﬁts and risks and the insertion, an E/M service is not reported since the E/M services are minimal.
- If the patient comes in for another reason and, during the same visit, a procedure is performed, then both the E/M services code and procedure may be reported.
If reporting both an E/M service and a procedure, the documentation must indicate a signiﬁcant, separately identiﬁable E/M service. Physicians may choose outpatient E/M visit level based on either medical decision making (MDM) or time. For code selection based on time, the time reported is total physician/qualified health care professional (QHP) time (face-to-face and non face-to-face) on the date-of-service. Time may be used to select a code level whether or not counseling or care coordination is the primary office or other outpatient service (codes 99202-99215). Note the "typical times" listed in outpatient E/M services codes of the AMA-CPT code set have been revised to depict a range of time. Providers should be sure to refer to the 2021 E/M changes to outpatient visits and consult with their third-party payers before instituting this coding practice to ensure compliance with specific plan guidelines.
A modiﬁer 25 (signiﬁcant, separately identiﬁable E/M service on the same day as a procedure or other service) is added to the E/M code to indicate that this service was signiﬁcant and separately identiﬁable from the insertion. This indicates that two distinct services were provided: an E/M service and a procedure.