-25 modifier

I saw a patient in the office for a breast abscess. I performed the appropriate established patient E&M with -25 modifier. I dictated the E&M note with the incision and drainage procedure as part of the E&M note. Do I need to dictate a separate note for the procedure, or can I just tag it on to the bottom of the visit note. And what needs to be dictatd (how much detail do "THEY" want)?

A few comments

First, you saw the patient for a painful breast or a lump or a red spot; if you saw her for an abscess, then the diagnosis was already known and there is no justification for an E&M, you just bill the procedure. Some even argue that with obvious things like abscesses or thrombosed hemorrhoids you cannot justify an E&M (but disagree with them.)

So assuming you document the E&M properly with a history, PE, and plan then do a procedure, you do not need to have a separate note, just a clear delineation in the note of the procedure with the usual "Procedure: I &D- after informed consent, the area was cleaned..."

modifier 25

what if I see the patient for "anal pain" and perform an appropriate E&M with appropriate documentation. During the exam I perform anoscopy (which has a CPT code). Do I need a modifier 25 for this E&M visit in order to bill the anoscopy? And, do I need to dictate a separate procedure note for the anoscopy...or can I simply include this in the exam portion of my note....Example..."Rectal: normal anal margin, normal sphincter tone, no masses. Anoscopy was performed which revealed no masses and a small internal hemorrhoid in the left lateral position." Would this be adequate to bill the E&M with modifier 25 and the separate CPT code?
Thanks in advance.

modifier 25 and anoscopy

You do need modifier 25 on the E/M when performing an anoscopy. These should both be paid on the same day according to coding rules, but some of the privates will try to call the anoscopy "incidental" to the E/M. Appeal them, and if you have to, write to the medical director.

I would accept the documentation you described without putting in a separate page in the record.