Ob-Gyn Coding Alert

Strengthen your case for CPT starred procedures by clearly identifying medically necessary and separately identifiable services. More detailed chart notes can help prevent common denials of evaluation and management (E/M) services and procedures when done to ob/gyn patients on the same day, our experts advise.

Simply writing that a 63-year-old white female presented with unexplained vaginal bleeding is not enough to support reimbursement for an endometrial biopsy. In this case the claim was originally coded 99212 (with no modifier) and 58100 with a diagnosis of postmenopausal bleeding (627.1) and folliculitis (704.8) linked to both services. The original coding was based on this simple chart notation and the claim was denied:

Original Chart Note

BP: 130/82 Resp: 18 Pulse: 60 Wt: 143# Ht: 65 inches (no change);

63-year-old female in apparent good health with unexplained vaginal bleeding, no HRT. Denies postcoital bleeding, uses lubricant, no dyspareunia. Has had 3 recent episodes of painless vaginal bleeding, none heavy. First 5 weeks ago, duration two days. Second last week, and third 2 days ago. Very light/one day only.

ROS neg. except some loss of urine on coughing. Chole 5 months ago. Annual exam 7 months ago. Pelvic exam normal except for apparent folliculitis on labia.

Impression: unexplained vaginal bleeding.

Plan: endometrial biopsy todayconsent signed.
Patient tolerated procedure well, only small amount
of tissue obtained. Sent to lab. Follow-up in office in one week.

More Information Was Needed

The initial documentation was too short and needed to be expanded in order for the claim to be paid.

By expanding on the services rendered at the time of the examination and by including separate notes for each service to clearly show that both were medically necessary and separately identifiable services the claim worked. The expanded claim met the criteria for a level 4 E/M service and would be coded 99214-25 (the modifier signifies that the service was separate and significant from the office procedure that day) linked to the postmenopausal bleeding and folliculitis, and 58100 linked only to the postmenopausal bleeding. The chart that finally got the claim paid looked like this:

Expanded Chart Note

CC: Unexplained vaginal bleeding in 63-year-old established patient; No HRT.

HPI: Patient presents today with the complaint of three recent episodes of painless vaginal bleeding, none of them heavy. The first one was 5 weeks ago and lasted only two days. The second was last week, and the third was two days ago. Each of these was very light and lasted only a day.

ROS: Const.: She is now 63 years old and in excellent health.

GU: She denies any postcoital bleeding, always uses a vaginal lubricant and denies any dyspareunia. She has an occasional loss of urine [...]