Each type is defined by meeting or exceeding the minimum requirements for two of three elements (see Table 1): In this month's column, we'll focus on quantifying the amount and complexity of data, like medical records, diagnostic tests and other information, that must be obtained, reviewed and analyzed.
He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.She is vice president of the Greater Pittsburgh, Pa., local chapter.John Verhovshek, MA, CPC, is Managing Editor at AAPC.Generally, if the E/M service is unrelated to the minor procedure (i.e., the E/M takes place for a different concern/complaint), the E/M service may be reported separately. Because the E/M service leads to the decision for surgery and hernia repair is a major surgery (90-day global period), and because the E/M occurs the day before the surgery (e.g., within the global period of the procedure), report the appropriate E/M service code with modifier 57 appended.If the E/M service occurs due to exacerbation of an existing condition, or another change in the patient’s status, that service may be reported separately as long as it is independently supported by documentation. Her medications include a multi-vitamin as well as Synthroid® 135 mcgs each morning. This will alert the payer that the E/M service should not be bundled into payment for the hernia repair.