Ob-Gyn Coding Alert

Never assume certain ob-gyn diagnoses merit high-level E/Ms

Your ob-gyn practice is more likely to report CPT 99213 and 99214 than other established patient E/M codes, but watch out. Payers audit 99214 more than any other E/M code.
 
Follow these tips to determine when you can bump your visit up to 99214 and when you should stay in the 99213 zone.

Tip 1: Nail Down 99213-99214 Elements

Pay attention to the differences in the descriptors for 99213 and 99214 (emphasis added):

- 99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family

- 99214 -- - a detailed history; a detailed examination; medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

You can successfully code and document level-four established patient visits (99214) for many of your ob-gyn patients by remembering the code's minimum criteria. Compare 99213's to 99214's E/M documentation guidelines.

Tip 2: Avoid These Upcoding Mistakes

If your ob-gyn's documentation supports a level-four visit, you should report 99214. But watch out for these hidden traps:

1. Make sure your doctors understand that medical necessity is the overreaching criterion that dictates the level of service they provide. Automated systems set up to document every possible piece of history and examination for every patient will certainly attract the attention of auditors. 

Payers and auditors may view obtaining a higher-level component than medically necessary just to charge a higher-level E/M service as -gaming the system,- says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

2. You should keep in mind that E/M codes aren't completely diagnosis-driven. Don't assume you can report higher-level E/M codes for ob-gyn patients -- base your E/M choice on the documentation.

Example: A patient moves out of state during her pregnancy. Your ob-gyn has seen her for only three visits. You-re coding the second visit. At this appointment, the ob-gyn documents an expanded problem-focused history and performs an expanded problem-focused exam, and the visit note supports medical decision-making of only low-complexity:

- limited diagnoses or management options

- limited amount and/or complexity of data to be reviewed

- moderate risk of complications and/or morbidity or mortality.

Despite moderate risk (say, to a pre-existing condition), this service merits 99213, not 99214.

Tip 3: 99213 for Every Visit Is a Red Flag

Some insurers put up red flags when a practice only reports 99213 for established patient E/M services, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

Payers wonder what type of patient care a practice is providing when it never codes anything higher or lower than that, she adds.

Solution: Choose your E/M code based on the ob-gyn's documentation every time, and your coding will naturally reflect the ob-gyn's range of services. Here's what you should look for with each code:

Test Yourself With This Scenario

Scenario: Mary Jane comes in to see the ob-gyn for follow-up for uterine prolapse. She has been using a pessary for six months but is complaining of increasing pressure and difficulty keeping the pessary in place. She indicates that she has also had some intermittent pelvic pain over the last six weeks.

The ob-gyn reviews Mary Jane's chart notes from the previous visit and discusses her new symptom of pelvic pain, asks if she is having any related abdominal pain (which she denies) or urinary problems, and reviews with her correct pessary placement techniques. She notes that she has been voiding more frequently, and a week ago she had some burning on urination. The ob-gyn also asks her if she has had any changes recently in activity, employment, diet and so on. The ob-gyn then performs a limited genitourinary exam and reviews the vitals taken by the medical assistant.

The examination reveals a slight increase in the uterine prolapse, and the ob-gyn now has evidence of a stage-one cystocele as well. In addition, the ob-gyn finds some adnexal tenderness but doesn't feel a mass. The abdomen is soft and nontender at this time.

The ob-gyn orders a urinalysis (UA) to check for possible urinary tract infection and an ultrasound because of the adnexal tenderness. The physician discusses with the patient that with this progression in the prolapse, surgery is now an option. Mary Jane says she will consider the recommended TAH/BSO and cystocele repair and let the physician know what she decides in a few days.

Solution: You should report this visit with 99214. Here's why:

History

Chief complaint: Follow-up and new complaints

HPI: Location, severity, duration, associated signs and symptoms (the ob-gyn documented at least four elements)

ROS: Review of both the genitourinary (GU) and gastrointestinal (GI) systems brings you to the level needed for a level-four service.

Past medical history: The patient has been using a pessary.

Exam

Vital signs (constitutional) and exam of the abdomen (body area) along with a pelvic exam that included the vagina, cervix, uterus and adnexa (GU system) equals a limited exam of the affected area plus two related body areas or systems (expanded problem-focused).

Complexity of MDM

The patient has several problems at this visit: uterine prolapse, vaginal prolapse, possible incontinence or urinary tract infection, pelvic pain, and adnexal tenderness. This means that in addition to established problems, the ob-gyn is also seeing and evaluating the patient for new problems. The ob-gyn did some further workup. This will bring the first element of complexity up to the highest possible level.

The amount of risk associated with the visit is moderate based on the table of risk (established problem with exacerbation and surgery as a management option).

Note: Medical data reviewed is not a factor because the doctor only ordered one lab test and an ultrasound (limited data). On the other hand, the other two factors (discussed above) support the moderate level of complexity needed to report 99214.

Conclusion: The history and complexity of MDM support a level-four service, whereas the exam indicates only a level-three service. Because only two of the three elements of documentation must meet or exceed the requirements for an established patient office visit, this note supports a level-four service.