A patient is seen in the office with paronychia of the finger. An incision and drainage was performed. Should an office visit be reported or just the procedure?

If a significant, separately identifiable evaluation and management (E/M) service was performed and documented separately from the procedure, the E/M visit would be reported with modifier 25 (significant, separately identifiable E/M service) appended. The incision and drainage code (10060 or 10061) would be reported without a modifier. The E/M service reported will be dependent on the performance and documentation of the required key components (history, physical examination, medical decision-making). Modifier 57 (decision for surgery) is used to identify an E/M service that results in the decision to perform surgery. Current Procedural Terminology (CPT®) does not differentiate surgeries or procedures as minor or major; however, the Centers for Medicare & Medicaid Services (CMS) identifies minor procedures as those with 10 or...

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