Question: An established, high-risk 72-year-old Medicare patient presents to the office for her annual well-woman exam. The patient is menopausal and there is a family history of endometrial cancer. Before the exam, she tells the physician that she has had three episodes of bleeding in the past year that concern her. The physician performs the complete well-woman exam, but then performs a separate history and exam for the patient’s bleeding. He orders the patient to have an ultrasound at a local clinic and schedules the patient for a follow-up visit the next week for an endometrial biopsy. Can I code a separate E/M service in addition to the well-woman exam?
California Subscriber
Answer: If your encounter notes prove that the physician performed a significant, separately identifiable E/M service in addition to the well-woman visit, then you can code the E/M separately.
Best bet: Go back and check the encounter notes. If you find a completely separate E/M, then report the following codes and modifiers for this encounter with your Medicare patient: