Originally shared in the May/June 2021 PPMA Newsletter

Response provided by Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC

Q: Can You Submit Both an E/M Code and A Minor Procedure Code for A New Patient?   

A: If both an evaluation and management (E/M) and a minor procedure are performed at the same encounter, you can and should code both if the E/M is significant and separately identifiable from the procedure. 
Whether the patient is new or established has no bearing on this.

Whether the procedure has a 0-, 10-, or 90-day global period has no bearing on this. The E/M needs to be separately identifiable. This means there cannot be any overlap in the work associated with the E/M and the work associated with the procedure.

Here are some examples of when it would be appropriate to code both a new patient E/M and a minor procedure if the documentation supports that a medically necessary, separately identifiable E/M was performed:

• New patient who gets an E/M for Tinea Pedis and a procedure for toenail debridement;
• New patient who gets an E/M for Xerosis and a procedure for at-risk callus debridement;
• New patient with an ingrown toenail who gets an E/M and a partial nail avulsion (CPT 11730) if the documentation supports an E/M that was separately identifiable from the procedure. If the “plan” section of this note only describes the procedure of a partial nail avulsion, there is no E/M there.

However, a separately identifiable E/M would be supported by a robust paragraph explaining the discussion with the patient regarding: his or her diagnosis; potential etiologies; treatment options for this diagnosis; potential risks; potential advantages and disadvantages of different treatment options; how to try to prevent recurrence; the patient’s questions that you answered; and the discussion you had about treatment options. An operative note of the procedure would be expected to follow in this example.