# Pessary E/M....Help!!!



## melheffley (Sep 11, 2012)

I need some serious help in coding pessary change e/m codes.  These are just straight changes, no fitting or new devices.  I don't think we are capturing the information needed in the notes and need to explain this to the provider.  Below is an example of a note by the doctor:

[Patient Name] is a 82 year old white femail, G3P3 who presents for a pessary change. She desires a pessary as her means of controlling her symptoms of prolapse.  She understands the care needed for a pessary and desires to proceed.  Alternative treatment options have been discussed at length and the patient voices an understanding of each option.

*Procedure*
The patient was placed in the dorsal lithotomy position.  Examination identifies Grade II cystocele and Grade III uterine prolapse. A #3 ring with support pessary was fitted without difficulty. The patient subsequently ambulated, voided and performed valsalva maneuvers without dislodging the pessary and without discomfort.  Care instructions were provided. Patient was discharged to home in stable condition.

*Assesment*
Uterine Prolapse 618.1
Cystocele 618.01

*Plan*
Premarin Vaginal Cream 0.625mg/g
Disp: 1 tube with 3 refills

Return in 3 months (sooner if problems)

Typically with this documentation only provided, our doctor would code this with a 99213. However, for this patient he states it is a 99214 because "it took longer".  

I'm not sure how to prove a 99213 let alone a 99214 for this.  If he is using the amount of time spent as a factor, shouldn't he have to state the amount of time spent with the patinet and possibly the to and from times?

Can anyone help me out with this? and with an explination that I can provide the doctor??

Thank you in advance for any help I might get!!


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## jdibble (Sep 13, 2012)

melheffley said:


> I need some serious help in coding pessary change e/m codes.  These are just straight changes, no fitting or new devices.  I don't think we are capturing the information needed in the notes and need to explain this to the provider.  Below is an example of a note by the doctor:
> 
> [Patient Name] is a 82 year old white femail, G3P3 who presents for a pessary change. She desires a pessary as her means of controlling her symptoms of prolapse.  She understands the care needed for a pessary and desires to proceed.  Alternative treatment options have been discussed at length and the patient voices an understanding of each option.
> 
> ...



I am a little confused on what type of visit this is - the patient came in for a pessary change?  The documentation by the doctor seems like the patient came in to have a pessary fitted?  Our doctors do pessary checks all of the time - the patient is evaluated and the pessary is removed, cleaned and reinserted.  With the documentation our doctors do, we can usually bill a 99213.

However, with the above documentation, first he states the patient is here for a change - then he documents a fitting, not a check.  There is no true history element, no exam and the MDM looks like it would be straight forward.  E/M would possibly be 99212, but definitely not a 99214.  If he wanted to bill on time, he would need to give the total time spent and then document that more than 50% of that time was spent in counseling the patient with the content of the discussion (and spent 25 minutes or more).  He cannot bill on time just because it took longer - only if he was counseling the patient for that time. 

I would go through his note with an auditing tool and show to him that he does not have enough information to bill the higher codes.  If the patient actually came in for a pessary insertion, than you would bill the code for pessary insertion, 57160, and you would not bill an E/M code.

Hope this helps - if anyone else has an opinion please advise!

Thanks,


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