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. The documentation must indicate either the key components (history, physical examination, and medical decision making) or time spent counseling. Counseling must be documented as more than 50% of the time spent face-to-face with the patient. Note the “typical times” listed in outpatient E/M services codes 99201–99215. For example, if an established patient is seen for 25 minutes, including 15 minutes spent counseling, report code 99214— this code lists a “typical time” of 25 minutes. The level of history, physical examination, and medical decision making do not matter in selecting this code. Providers should consult 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.
Reporting Contraceptive Services with Other Services
Under some circumstances, an Evaluation and Management (E/M) services code, a procedure code, and a HCPCS code may all be reported.