Ob-Gyn Coding Alert

Here's how to make diagnoses codes support your claim You could be missing out if you don't report preventive medicine counseling codes 99401-99404 on the same day as a problem-based E/M visit when your ob-gyn counsels the patient on an unrelated issue. Crux of the problem: "Sometimes a patient comes in for preventive care/counseling without a specific problem or complaint, and we-re hesitant to code these visits correctly because we-re worried about the insurance company not paying for the service," says Karen Green, CPC-H, OGS, coding specialist for Eau Claire Women's Care in Wisconsin. "But what we have to remember is that we have to code correctly to the service, not code to be paid." Learn how to determine which code to report and what documentation you need using these two scenarios. Decide How to Code These Situations Situation 1: The ob-gyn spends 15 minutes discussing and prescribing birth-control pills during a preventive medicine counseling session with an adolescent patient. How should you report this? Situation 2: An established patient presents to your ob-gyn and wants counseling as to whether she should have the HPV vaccine. Once she learns about its benefits, she wants to have the vaccine on the same day. Answer 1: Conquer This Birth-Control Example You should report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and link it to V25.01 (Encounter for contraceptive management; prescription of oral contraceptives). When the physician prescribes alternatives such as the contraceptive patch during a preventive medicine counseling session, link V25.02 (Initiation of other contraceptive measures) to the appropriate code for preventive medicine, individual counseling (99401-99404). However, code V25.02 excludes intrauterine devices (IUDs). Remember: Because 99401-99404 are time-based, your physician must document the amount of face-to-face time spent counseling, and the content of the counseling is crucial, says Cindy Foley, billing manager for three ob-gyn practices in Syracuse, N.Y. Notes for the counseling visit should include references to pamphlets or other materials the physician reviewed with the patient.
Note: If an adolescent comes in for a follow-up visit after an initial birth-control prescription, you can report a regular E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with a birth-control diagnosis (V25.4x). Reason: The physician is now monitoring the side effects of the drug, coding experts say. Most of these visits will involve counseling. To make sure your documentation has what it takes, you should go through this checklist: 1. Does the documentation reveal the total face-to-face time in the outpatient setting?
2. Does the documentation describe the content of the counseling or coordination of care?
3. Does the documentation reveal that the physician spent [...]