Ob-Gyn Coding Alert

Checking both the 1995 and 1997 guidelines can make a difference

If you-ve been relying on the safety of 99213 for established patient E/M visits, you could be flagging your practice for an audit.

Read the following example, fill out the chart, and see how your coding measures up against 99214's (Established patient office visit -) history and exam components. Your office could be sacrificing $30 for visits that really qualify as 99214 rather than 99213. Don't Overlook History and Exam Elements Ob-gyns often perform history and examination elements but fail to record that information. They may not realize that jotting down these details could justify a 99214 instead of the safety of 99213.

Every visit isn't going to be a 99213, says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. -In fact, some insurers put up red flags when a practice never bills any other E/M codes. They wonder what type of patient care a practice is providing when it never, ever bills anything higher than that. Or they wonder why every visit warrants a 99213 and none ever justifies a 99214.-

Rule of thumb: If your documentation supports billing 99214, you should report it, says Betty Carpenter, CCS-P, coding and compliance manager for a practice in Grand Rapids, Mich. Break Down This Ob-Gyn's Documentation Read the following visit details and documentation, and see which E/M code you would choose:

Example: Wanda, a 40-year-old G5, P4 who has had a tubal ligation, comes in for a follow-up regarding a number of issues related to her cycles. The ob-gyn comes in and asks about:

- her history of irregular cycles, dysmenorrhea and menorrhagia in the past.

- her medications. She was well controlled on DepoProvera, but she developed mood dysfunction and stopped the Depo.

- her cycles. In the past year, she has had to return to cycles every three to four weeks with dysmenorrhea for four days and intermittently menorrhagia, although she is not heavy with every cycle.
 
- other medical issues. She has a pituitary microprolactinoma and thyroid dysfunction, which is being followed by another physician but she is not now taking any specific medication for her pituitary. She is not allergic to anything. Then the ob-gyn asks her:

- If she has had any headaches, visual changes, dizziness.

- If she has had any chest pain or palpitations.

- If she has had any shortness of breath or cough.

- If she has gastrointestinal issues, such as diarrhea, constipation with spasm and pelvic pain. She says she recently had a colonoscopy and was diagnosed with diverticulosis and visualized bowel spasms. She just started a bowel regimen in the past few days.

- If she has any vaginal bleeding or discharge, any stress urinary incontinence [...]