Ob-Gyn Coding Alert

See how you fared when it comes to choosing codes.

After you’ve read the scenarios carefully on pages XX and decided on your answers, see how yours compares with those of our experts.

Choose 99202 for Scenario 1

Although the coder in this situation reported 99204, the correct answer is 99202, based on the documentation. Here’s why.

For the history portion, the ob-gyn went into the one-to-three required HPI (location vaginal, quality discharge, associated sign/symptom itching), listed the one pertinent ROS (denies urinary problems), and did one of three PFSH (pancreatitis). This means the ob-gyn documented the history as expanded problem-focused.

For the exam portion, the ob-gyn documented a detailed examination under both the 1995 and 1997 guidelines. He performed an extended exam of affected organ system plus eight additional areas/systems, based on the 1995 guidelines. (Tip: A comprehensive exam would have required examination of eight organ systems, not a combination of body areas and organ systems.) For the 1997 guidelines, he also performed a detailed exam based on documenting 16 exam elements. This was not a comprehensive exam under the 1997 guidelines because the ob-gyn did not document two exam elements from each of nine systems.

For the medical decision-making, the documentation of the three required components shows it was of low complexity. The diagnosis and management options would be considered “multiple” because this was a new problem with no additional workup planned. But the amount of data reviewed or ordered was “limited” (mammogram ordered and Pap smear performed), and the risk was “low” due to the presenting problem.

Taking into account these three factors, you should report 99202 because the history is only documented as expanded problem-focused. For instance, the review of systems only includes one system. Even though the exam should have made this a higher-level visit, the HPI doesn’t have enough documentation to account for a higher level. On new patients, each of the three components must meet or exceed the level required for the code you are billing.

No New Patient Code Scenario 2

This is an example of new patient visit in which the ob-gyn does not document any counseling time and does not perform an exam. The coder who received this physician note reported 99204.

In this case, you cannot bill a new patient visit at all. CPT® does not stipulate that you must report a new patient visit; they only list the criteria that must be present to do so. In the case of this scenario, you don’t have enough detail for a new patient code.

Also, keep in mind that you shouldn’t append modifier 52 (Reduced services) on a new patient visit.

Option 1: Your can report an established visit (such as 99213, Office or other outpatient visit for the E/M of an established patient ...) if you can meet only two out of the three criteria. 

Option 2: If the patient is on Medicare, you can only report the unlisted E/M service code 99499.

Option 3: The first thing you should do is check with the physician as to the time spent on counseling and/or coordination of care. If 50 percent or more of the visit involved these elements, you can use time to determine a code for a new patient visit once the physician has added this information as an addendum to the record. But remember, that the counseling note should be of sufficient content to warrant the time spent.