# Challenging Scenario



## m.j.kummer (Apr 29, 2010)

I am looking at some claims for an OB/GYN practice. One of the situations is this.

33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".

She counseled the patient regarding the findings, possible diagnoses, and possible treatment options. She documented the discussion and time spent very clearly.

The patient decided to have surgery the following Monday. The patient returned to the clinic a third time (the same date) with her husband. The doctor explained the results of the testing's and exam to the patient and her husband answered all of their questions and documented the start and stop times of the visit. I am posting what she coded and then what I think it should be coded as and I would like your opinion.

Provider Coding
1st visit same date:
CPT DX
99395 V72.31
99213 V72.31; 620.2; 625.3; 250.00
76830 620.2
81002 V72.31

2nd visit same date:
99213 789.33; 625.3; 250.00; 218.9
76830 789.33

3rd visit same date:
99215 625.3; 250.00; 218.9 752.11; V26.49; V72.83

She did not use any modifiers.

I believe it should be coded as follows. My only concern is that the rules say not to bill prolonged care with a preventive medicine visit. I think in this case it is OK because there is a separate E&M code. The total time spent in counseling is 90 minutes. Please let me know what your opinion is.

Visit 1 (Claim 1)
CPT     DX
99395 V72.31; V76.47; V73.81 (she did provide these services) 625.3
81002 V72.31

2nd & 3rd visit same date (because all of the appropriate diagnosis codes will not fit on one claim)

99215-25 789.33, 625.3, V72.83
99354 789.33, 625.3
76830 789.33
76830-76 789.33, 625.3, V72.83

I want to use this case in my advanced E&M coding course and want more than my opinion on the accuracy of the coding. Please let me know what you think.


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## rlcohen76 (May 19, 2010)

I think the provider coded the first visit correct expect a modifier 25 is needed on the 99213. The CPT book states that if an abnormality is encountered in the process of performing a preventive medical examination and the problem is significant to require additional work then the approriate E&M should also be reported  with modifer 25 added to indicate a signifcant & seperate E&M service. 

Was the third visit on the same day as surgery? that is pre op then.


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## FTessaBartels (May 19, 2010)

*3 visits in one day*

If I understand your scenario correctly the patient came to the office three separate times in one day ... Visit # 1 preventive with discover of mass ... Visit # 2 ultrasound and discussion of treatment options ... Visit # 3 counseling (along with husband) re surgery risks, benefits, outcomes, etc.

If I have that right, then I agree with your coding (though I didn't check the ICD-9 codes).

You would roll all the work of "sick" visits together and code the 99215 plus appropriate prolonged service as time is documented. You will need a -25 modifier on the 99215 and on the prolonged services code(s). 

If these visits are within 48 hours of the surgery you'll probably also need a -57 modifier. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## mitchellde (May 19, 2010)

m.j.kummer said:


> I am looking at some claims for an OB/GYN practice. One of the situations is this.
> 
> 33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".
> 
> ...



MJ,
I do agree with your coding but I have a couple of questions, Why did you code for a vaginal pap screening?, and why did you code for a repeat ultrasound?  From the documentation I see only 1.  Also you have 8 dx codes per claim and you cannot submit 2 claims for one day per patient they will hit as duplicates so you will need to put it all on one claim but you have 8 dx slots so it should work fine.


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