Ob-Gyn Coding Alert

Learn why ‘review of systems unremarkable’ doesn’t make the grade.

To avoid incorrectly reporting higher-level new patient visits, you should only pick your E/M code based on the lowest level of any of the three components your ob-gyn documents: history, exam, and medical decision-making.

Learn What a Higher-Level Code Includes

You can use a higher-level E/M code if you meet the requirements with solid documentation detailing history, exam, and medical decision-making.

Avoid this pitfall: What many experts see in performing audits is the lack of information in the history requirements - specifically review of systems (ROS), and past, family, and social history (PFSH).

For example: If you use 99203 (Office or other outpatient visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity), you must have a detailed history, detailed exam, and at least low-complexity medical decision-making. This means that the provider must document a chief complaint, an extended HPI (history of the present illness consisting of four or more elements or the status of three or more chronic or inactive conditions), an extended ROS (the system directly related to the presenting problem plus additional systems for a total of two-nine systems), and at least one element from the PFSH.

The detailed exam, under 1995 guidelines, requires the ob-gyn to perform an extended examination of the affected organ system or body area plus any additional related or symptomatic areas. This usually translates into an examination of between two to seven organ systems or body areas. Under the 1997 guidelines, you have three choices: examining six systems and documenting two exam elements from each system, documenting 12 elements from two or more systems, or documenting any 12 elements from the defined genitourinary single-system exam. The MDM needs two of these three elements: limited number of diagnoses or management options, limited amount or complexity of data reviewed, and/or at a minimum, low risk of complications.

Identify Problem Areas for 99204, 99205

The requirements for higher-level E/M codes only increase, and your documentation must reflect that.  For example, the new patient visit 99204 (... a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity) requires an extended HPI, a complete ROS (10 or more systems), a complete PFSH (at least one element from past, family and social history), a comprehensive exam, and moderate risk.

For 99205 (a comprehensive history, a comprehensive examination, and medical decision-making of high complexity), you’d need to meet the same requirements, except the medical decision-making must be high complexity.

Problem areas: Each system the ob-gyn reviewed as well as the past, family, and social history must be documented.

For example, sometimes auditors will see “Review of systems unremarkable,” but that doesn’t meet the requirement for the ROS, because in order to be counted, each system has to be referenced - even if it’s unremarkable.

Another problem can occur with the exam section. The ob-gyn has to document each system he examined, even if it’s normal.

Put Your E/M Savvy to the Test

Now that you’ve been refreshed on choosing higher- versus lower-level E/M codes, examine the following two scenarios closely.

Scenario 1: Your ob-gyn documents the following encounter:

Lynette comes in new to us having some vaginal discharge and itching. She denies any urinary problems. In August she had a bout of pancreatitis, is being treated for that. No other complaints. On examination, HEENT was normocephalic, atraumatic. EOMI. Neck is supple. No thyromegaly or adenopathy. Lungs are clear. COR is regular rate and rhythm. Breasts are without palpable masses or discharge. No axillary adenopathy. Breast self-examination was reviewed. Her abdomen is soft and nontender. No hepatosplenomegaly. No groin adenopathy. Cervix, vulva, and vagina without gross lesions. No discharge evident and no redness at this time. Uterus is anteflexed and mobile. I do not appreciate any adnexal masses. Pap performed. Gave her a slip for the mammogram. Imp: nonspecific vaginitis. We will see her on a p.r.n. basis if discharge or itching return.

Scenario 2: You receive your physician’s notes for an initial visit for infertility:

Deanne is a 29-year-old married Caucasian nulligravid female who presents today for an initial visit for primary infertility and associated irregular cycles on cycle day number 26. She is found today to have bilaterally polycystic ovaries.

Plan: Estradiol, luteinizing hormone, progesterone as well as a rubella titer was drawn. Androgen panel drawn.GC, urea plasma and chlamydia cultures are procured and sent.

I suspect this patient has not ovulated yet, therefore patient to return to clinic to recheck follicular development. Patient may need Provera withdrawal bleed to proceed with cycle monitoring as follows:

Cycle day number 3 labs on cycle day 2-5, HSG on cycle day 7-14, and a semen analysis on her husband. We discussed PCOS and implication with fertility. Multiple brochures and prenatal vitamin samples were given. 

Turn to page XX for the answers.