Can you bill an E&M code with a procedure?

Name: E/M Documentation and Coding: Update for Ambulatory Visits
Uploaded: 2022-08-16T15:00:05+00:00
Duration: 42 min 34 s

Editorial team InsuredAndMore.com Published on October 26, 2026

Yes, you can bill an Evaluation and Management (E/M) code with a procedure on the same day if the E/M service is significant, separately identifiable, and goes beyond the usual pre- or post-operative care associated with the procedure.

Key Requirements for Billing Both

Distinct Service: The provider must perform a separate evaluation that justifies deciding to do the procedure or addresses an unrelated/additional problem.
Proper Modifiers:
- Append Modifier 25 to the E/M code for minor procedures with a 0- or 10-day global surgical period.
- Append Modifier 57 to the E/M code if the decision for major surgery (90-day global period) was made during that encounter.
Clear Documentation: The medical record must feature distinct notes for both the E/M service and the procedure. The work cannot overlap with routine tasks like obtaining informed consent or giving post-op instructions.