EM Coding Alert

Question: A patient presents for her yearly examination, and the ob-gyn decides to fit her with a pessary and insert it during the same visit. Do I still need to report an E/M code with 57160?

North Dakota Subscriber

Answer: Yes, you will report a code from the 99395-99397, (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, ...) range to represent the preventive service. Then, report 57160 (Fitting and insertion of pessary or other intravaginal support device) for the pessary insertion procedure. 

Remember to add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M service to communicate to your payer that the office visit was separately identifiable from the procedure and thus deserves separate payment.