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 [...]