Wiki Preventive care with an E/M

If a patient comes in and have a CPE ( Preventive care) done and the provider documents Atypical mole, but only wrote a referral to another provider, nut not other work up can you code a E/M?

If all the provider did was say "hey, that mole looks odd - go see a derm", my opinion is that does not meet the requirement to bill a separate E&M with -25.

Per CPT/Preventive medicine guidelines, if a problem/abnormality is encountered in the process of performing a preventive medicine E/M service that does not require additional work then a problem-oriented E/M service should not be reported. From what you stated here, it doesn't appear that any additional work-up was done for the atypical mole other than a referral to another provider. Hope this helps!