# Pelvic exam along with E/M code



## jmcdaniel (Jul 19, 2010)

If a pt comes in for a follow up for hypertension and diabetes but also mentions that she has a yeast infection and the dr does a vaginal culture, what code do you use for the pelvic exam?  I billed it as a 99213 with a 25 modifier for the hypertension and diabetes then Q0091 for the pelvic exam but it was denied as bundled.  Does anyone know of a pelvic exam code to use with dx 616.00? Thanks.


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## bonzaibex (Jul 22, 2010)

The pelvic exam is considered part of the office visit, so it needs to be incorporated into your E&M code level.  The only separate pelvic exam code I can think of off hand is the "Pelvic Exam Under Anesthesia" code, but that's only used if general anesthesia is necessary to complete the exam.

Becky, CPC


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## preserene (Jul 23, 2010)

*Pelvic Exam with E/M Code*

Pelvic Exam  with E/M code.
 Here the patient comes for follow or check up – office visit , established for follow up, with new cc of vaginal itching.
I would report  with the  Code E/M service  99212
May I know how you derived  at 99213,  instead of 99212.
But if the patient is coming for Preventive Medicine Services- routine  comprehensive service on A HEALTHY PERSON,  include multisystem examination in which the  pelvic examination ( an organ system examination, and not a special EUA under GA)  is incorporated.
But  when the healthy client states a  significant problem/abnormality so much so to require additional work to perform the key components of a problem oriented E/M Service, then appropriate office Code should ALSO be reported. Modifier -25 appended to the office code. 
If  it is a trivial  problem, it should not be reported.
Can  that rule be  applied to this Service also? If so,  can the  Modifier 25  fit for this situation? The office code I would give is 99212 for this.
Another point I would like to clarify is , does the follow up office code itself for BP and Diabetes  requires 99213?
 I think this might not require a presence of Physician. But the new CC requires a Physician definitely.  Well, it is seen by the Physician and the new significant CC can fit for the code 99212.  Isn't it?
For the benefit of higher level coding, 99212 will suffice this situation I think.
                              I am in a fix !! 
Leave alone the Vaginal culture  part for Microbilogy Coding.

Becky , can I ask you to enlighten me better on my confusion please?


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## efrohna (Jul 23, 2010)

pmedical1 said:


> If a pt comes in for a follow up for hypertension and diabetes but also mentions that she has a yeast infection and the dr does a vaginal culture, what code do you use for the pelvic exam?  I billed it as a 99213 with a 25 modifier for the hypertension and diabetes then Q0091 for the pelvic exam but it was denied as bundled.  Does anyone know of a pelvic exam code to use with dx 616.00? Thanks.



Hi Pmedical1,
Why are you coding a Q0091 for a pelvic exam?  Q0091 is a code for obtaining a pap smear specimen, not pelvic exam.  If this was a Medicare patient, there is a screening breast & pelvic exam code - G0101.  However, I do not know if other payers recognize this G code?  
Good luck,


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## bonzaibex (Jul 23, 2010)

Wow, Preserene---you just made my eyes cross with all that info.  Let me answer what I can in pieces:
99212 vs 99213: The E&M level is wholly dependent on the key components documented - hx, exam, & MDM - in the chart note.  I wouldn't presume to choose an E&M level without looking at the documentation, but based on dx of HTN, DM, & vag inf, I should hope there's enough documentation to warrant at least a level 3.  
Presence of Physician:  I'm assuming, from the original question, that the patient saw the physician for an exam and did not come in for a simple BP/glucose level check.  The physician is the one who determines what the follow-up plan is.  Again, a determination cannot be made based on the info above.  Only the doctor & chart note will dictate the level of follow-up exam needed & done.
Preventive + Problem E&M:  You are correct.  If pt presents for routine preventive exam and a non-trivial problem is encountered during said exam, then a separate E&M code is billable.  Again, E&M code will be based on documentation.  Physician/NPP must document this separate and apart from the preventive documentation.  "Separate and apart" are key words - best CYA bet is for physician to document as a wholly separate encounter.  Modifier 25 would be used on the problem E&M code in order to separate it out from the preventive code.  
Vaginal Culture:  Yes the lab is going to bill/code for the actual vaginal culture.  The physician would bill for evaluating & managing the problem only.  

Phew--did I answer all your questions?

Becky, CPC


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## preserene (Jul 23, 2010)

Thank you very much, Becky. Your experience really  brings credits to enlighten me. So the level 3 here is inclusive of the first code which does not require a Physician? well I got the point. Thank you.
Yes, viewing the document all the more important. But you know, in the forum site, we are not /people cannot dump the whole stuff. So person like me, get stuck with the little knowledge we have.As for me, the E/M stuff is always a night mare.
 But one thing I find from the forum , is real awesome benifit of learning from 'trial and error' from ours, catch up and gain' from others experience and knowledge, a lot& lot and loads.
It is awesome! you are amazing too.


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## MJ4ever (Jul 24, 2010)

*new chief complaint*

Hello Pmedical1

The pelvic exam is included.
But, I would code for the procedures performed.
Yeast infection would be 112.1 (depending on the site) and more likely the provider performed a wet prep and KOH. If these tests were done in the office by the provider such as under the microscope and slide for KOH, these can be billed with 87210 and 87220.

Also, to determine 99212 and 99213, I would consider the follow-up dx of HTN and DM, plus the new problem.
If HTN and DM have become worse and need new prescriptions, that should definetely qualify for a 99213. Plus, when prescribing a medication, this is considered a moderate medical desicion making.

I would go for a 99213.

Please let me know what you think.

Barbara


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## jmcdaniel (Aug 20, 2010)

*Thanks*

Thanks everyone for your input.  My instinct was correct.  All of your advice is appreciated!


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## daedolos (Mar 19, 2019)

*Test Question Query*

QUIZ Question

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Clinic Note:

CC: Established patient presents for routine examination

Subjective: Sharon is a 42 y/o female patient who presents today for a routine physical examination.

Objective: BP 120/80 Pelvic exam: normal external genitalia. vagina w/o discharge except for a scant amt of white discharge that appears normal. Cervix: multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.

Assessment: #1) normal BP #2) normal pelvic exam

Plan: return in one year as needed

CPT Code: ________________

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~



How would you code this? I am guessing that the answer required involves an evaluation and management decision but I am puzzled by the CPT Code request at the end of the question.

Peace
?_?


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