Ob-Gyn Coding Alert

Applying this modifier alerts Medicare that you know the service isn't covered To estimate what your practice should charge a Medicare patient when your ob-gyn performs a preventive service as well as an E/M service at the same visit means applying the "carve out" rule. Depending on whether the patient's annual exam is covered, your outcome will be very different. Our experts break this sometimes puzzling rule into terms you can understand. Follow This Advice for Medicare Carriers For Medicare beneficiaries, you should take your normal charge amount of the preventive service minus the charge amount for the sick visit. This will give you the total amount you can bill the patient for the preventive part of the visit. Example: A 66-year-old established patient comes in for her yearly exam. Last year when she presented for her annual exam, you billed Medicare for the breast, pelvic, and Pap, and it was reimbursed. Remember: "Medicare will pay for these services once every two years," says Arlene J. Smith, CPC, insurance specialist at Tacoma Women's Specialists in Wash. When the ob-gyn enters the examination room, the patient complains of pain in her left-lower quadrant and blood in her stool. The physician documents an expanded problem-focused history regarding the problem, then completes the annual exam and collects a Pap smear specimen. He orders an abdominal ultrasound and performs an immunoassay test for fecal blood. First, you would report a well-woman exam (99397, Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender- appropriate history... established patient; 65 years and older) with modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) appended. Modifier GY tells Medicare you know this is not covered, but you need a denial so the patient's secondary insurance will pay the non-covered portion, Smith says. Link this code to V72.31 (Routine gynecological examination). Secondly, according to your ob-gyn's documentation, you might add 99213 (Office or other outpatient visit for the evaluation and management of an established patient -) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Link that with 789.04 (Abdominal pain; left lower quadrant) and 578.1 (Blood in stool). No double dipping: You must be vigilant about checking your documentation, as "you cannot use any part of the documentation for the preventive exam to determine the level of service for the E/M code," Smith says. Tip: Ask yourself, "can I find enough carved-out history, exam and medical decision-making to support an E/M service that is not part of the preventive care?" says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, [...]