Ob-Gyn Coding Alert

The annual preventive well-woman exam is one of the ways a progressive ob/gyn practice promotes the health of its patients. But according to Jan Rasmussen, CPC, a coding consultant and instructor for Med-Learn, a medical practice management training and consulting firm, proper coding for these preventive medicine services can be challenging. Part of the challenge is that these services fall into the preventive medicine codes and are separate and distinct from the disease-oriented codes. The problem is that very often, the well-woman exam encompasses more than just an exam. Here is a review of various well-woman exam scenarios and some tips on how to code for them to increase your chances of being adequately reimbursed.

1. A straightforward preventative medicine service. In this situation, a woman makes an appointment for a preventive exam strictly because it is time for her check up and she wants to insure her health and stay disease-free. When making the appointment, she offers no complaints, comes in as scheduled, and the exam goes as planned. The physician obtains a comprehensive history and performs a comprehensive exam including a pelvic and breast exam. The CPT codes used in this case are the Preventive Medicine Services codes 99384-99387 for new patients and 99394-99397 for established patients. These codes are linked to the ICD-9 diagnosis code V72.3, the code used for a gyn exam with or without a Pap smear. This diagnosis code is only to be used with preventative medicine codes and never with office visit codes.

Tip: Some women who are healthy and free of disease symptoms let years pass between exams. If a patient has not received any professional service from you or a member of your group (within the same specialty) for three years, you can consider her a new patient.

2. Exam with counseling. Despite the lack of disease, few well-woman exams are without some counseling and discussion between patient and provider. Consider the situation in which a woman comes in for a preventative exam and everything goes as above, except since her last visit, the woman has experienced a lifestyle change and has some questions for the physician. The physician spends 15 minutes beyond the normally allotted time counseling her about birth control, disease risks and disease prevention.
Can you code for this extra time? Rasmussen says, absolutely not. These sorts of activities, according to the CPT, are already included in the Preventive Medicine Services codes. These services include counseling/anticipatory guidance/risk factor reduction interventions that are performed on the same day as the examination and are not billable as separate services. They are viewed as part of prevention.

Tip: If a patient has a significant issue that needs extensive preventive counseling or discussion, make a new appointment and schedule her to come in on another day. Then use the 99401-99404 counseling codes. But remember, these codes are not for counseling about symptoms or an established illness, but strictly for promoting health and preventing injury or illness. For those patients with symptoms or established illnesses, use the appropriate office, hospital, consultation or evaluation and management codes.

3. Exam with a problem. Patients often save up problems until they come in for their annual exam. In this scenario, a patient presents for a routine exam and then explains that she has been having symptoms of a potential disease. Or, in a similar situation, during the course of the exam the physician discovers that the patient has a problem. Wellness codes, by definition, are for the patient who is asymptomatic. In this scenario where a problem is found, you have moved beyond the scope of the preventive medicine codes and in addition to coding for the preventative service may be able to code for disease-oriented services by using the 25 modifier. But whether or not you can use the 25 modifier will depend on how much additional work is done. The requirements for using the 25 modifier can be tricky. (See article on page one of this issue for a full explanation of when and how to use this modifier.)

Tip: Even if a problem is discovered during a preventative exam and the physician spends significant time on the problem, do not automatically change the visit to an office visit for billing purposes. You will want to record that the preventive exam was completed. In addition, such a change could be considered fraud if the patient does not have preventive coverage.

4. Annual exam with an old problem. This situation is especially common in older women. A patient comes in for her annual preventive visit, and during the course of the exam, the physician addresses some preexisting condition. Again, you are still providing preventive medicine services, which are not about disease, but being a good provider, you will probably address the old problem either in the history or exam portion of her visit. The extent of the work done with the old problem will determine whether you can use the 25 modifier and code for additional services. According to Rasmussen, simply having a brief discussion with a patient about her past hypertension and current blood pressure is not enough to warrant additional coding and reimbursement.

5. Partial exam. Sometimes less than a comprehensive history and physical exam is performed. In this case, there is some debate as to what should be done. According to Rasmussen, To correctly report this service, you should report it with a 52 modifier (meaning a less extensive service was provided). The AMA indicates the correct coding of this service would be to use office visit codes 99201-99215 based on the extent of the history, physical exam and the complexity of medical decision-making documented, along with the diagnosis code indicating a routine physical. However, using AMA guidelines may not adequately indicate to the insurance carrier the exact nature of the service performed.

Rasmussen goes on to say, Many managed care contracts have required quotas for preventive medicine services. If a managed care company is using CPT codes for statistical analysis, you could jeopardize your contract by incorporating the AMA coding guidelines for preventive services that do not meet guidelines for a comprehensive history and a comprehensive exam.