Bundle into EM procedures:

Many payers bundle an evaluation and management (E/M) service when reported on the same day as a minor surgical procedure.

The National Correct Coding Initiative (NCCI) edits commonly combine evaluation and management (E/M) services with minor surgical procedures, in accordance with the policy set by the Centers for Medicare & Medicaid Services (CMS), which states that, "The initial assessment for minor surgical procedures and endoscopies is consistently encompassed within the comprehensive surgical care package."

What is preoperative EM?

Preoperative evaluation and management (E/M) refers to the comprehensive assessment and preparation of a patient before undergoing a surgical procedure. It involves a thorough evaluation of the patient's medical history, physical examination, and diagnostic tests to ensure that they are in optimal condition for surgery. The primary goal of preoperative E/M is to identify any potential risks or complications that may arise during or after the surgery and take appropriate measures to minimize them.

This preoperative EM is bundled into the surgery and is not coded separately.

If a patient comes in for a planned procedure and an evaluation and management (EM) service is done, the EM service is included with the procedure and only the procedure is coded.

For example, if a patient came in on January 1st and the physician did an EM service and then decided to do the surgery on January 7th.

On January 7th, when the patient returns for the planned surgery, the physician does an EM service before performing the procedure. In this case, the EM service is considered a preoperative EM and is not coded separately. It is seen as the evaluation needed before performing the surgery.