Evaluation and Management Service on the Same Date as an Office Procedure

Question:

A patient came into the office for a balloon sinus ostia catheterization and dilation of the maxillary, sphenoid and frontal sinuses bilaterally. My surgery scheduler has already obtained pre-certification for the procedure as it is covered in the office setting. I performed an examination and then did the procedure. I then performed a sphenoid, frontal, and maxillary dilation bilaterally. Can I bill an E/M service since I examined the patient?

Answer:

No, since the focus of the visit was the procedure and you have already obtained precertification for the procedures on the sphenoid and frontal sinus dilation (CPT 31298-50) and the maxillary dilation (31295-50), the E/M service is inherent to the procedure and should not be reported separately.  In this situation there is not a significant separate identifiable justification for an E/M service.

*This response is based on the best information available as of 7/03/25.