Ob-Gyn Coding Alert

In the course of providing a service or performing a procedure, there are often times when circumstances require a change in what was planned. According to the CPT, a modifier provides a means for reporting that change. The 25 modifier allows for the reporting of a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.

According to Melanie Witt, RN, CPC, MA, ACOG program manager in the department of coding and nomenclature, there are three common instances when an ob/gyn practice may use the 25 modifier.

A preventive medicine exam with a sick visit. This situation is extremely common. A woman comes into the clinic for her annual gyn examination, and during the course of the exam and history, her ob/gyn discovers a problem, and then does extra work on that problem that would not usually be included in a normal preventive exam. For example, during the history portion of an annual exam, a middle-aged patient on birth control pills reveals that she has been having breakthrough bleeding. She was not worried enough to make a separate appointment and was now just mentioning it because the physician was inquiring about problems. The ob/gyn asks a few more questions and soon discovers that the patient is experiencing a problem that needs additional evaluation and management. Following CPT guidelines, the physician performs the key components of a problem-oriented E/M service. This modification to the exam is enough to allow for the use of the 25 modifier attached to the office visit code to show additional work was done, and to hopefully receive additional reimbursement.

In the above case, where the patient comes in for an exam and a problem is worked up as well, use the appropriate preventive medicine code (99384-99397) and link it to the V72.3 diagnosis code. In addition, use 99201-99215 for the office visit followed by the 25 modifier. Then link the office visit to the proper diagnosis code (in this example 626).

According to Witt, the key to correct use of the 25 modifier in this situation is to make sure that the additional work is significant enough and includes documentation of the additional history or medical decision-making. Simply noting the complaint and ordering tests during the preventive exam may not be enough for a 25 modifier, she cautions. The coding expert recommends that ob/gyn caregivers literally draw a line on the chart between their documentation of the preventive services and their notes on the disease-oriented services to show that the two are distinctly separate. The chart itself will tell if [...]