EM Coding Alert

Question: If a patient was seen by her Primary Care Physician for an annual checkup, no pelvic or breast examination, we bill the visit with the preventive CPT^® code 99395 with DX Z00.00. Patient returns two weeks later and sees a Primary Care NP in the same practice for a breast/ pelvic examination and Pap smear. Should I bill this visit with a problem E/M with the DX Z12.4? Patient did not want the Primary Care Physician to perform the pelvic examination. The insurance is also commercial, so Q0091 is not billable.

Florida Subscriber

Answer: First, you need to have some conversations with your patients about this. Your practice is not going to be reimbursed for two preventive visits in the same practice within two weeks of each other.

For the second visit, bill a problem E/M visit (99212- 99215, Office or other outpatient visit …) linked to both Z12.4 (Encounter for screening for malignant neoplasm of cervix) and Z12.39 (Encounter for other screening for malignant neoplasm of breast), and keep your fingers crossed.

Every female patient, when scheduling an annual, needs to be informed that they might have to pay out of pocket for the second visit and have her schedule the annual with a provider she feels comfortable with for the Pap and breast exam.