Ob-Gyn Coding Alert

Two patients are seen in your ob/gyn practice. One woman is in for her annual Pap smear and pelvic exam. The other is in because she has been suffering unexplained abdominal pain. Both women will probably give a comprehensive history and receive a comprehensive evaluation. But, the codes billed for each of these procedures and the documentation required by the physician may differ greatly.

Confused? Youre not alone.

Even though the 1997 Evaluation and Management (E/M) guidelines have been put on hold indefinitely, the terms comprehensive history and comprehensive examination, as used in the CPT and both versions of E/M guidelines are causing a great deal of confusion for many ob/gyn coders. This confusion centers on the definition of these terms, the difference in documentation between the 1995 and 1997 guidelines, and whether the E/M guidelines apply to preventive medicine services, such as well-woman examinations. Here are two important points in understanding this dilemma:

1. The E/M guidelines apply to office visits, but they do not apply to preventive medicine services. Therefore, the requirements of a comprehensive history and a comprehensive examination in the guidelines are not applicable to preventive medicine services, including well-woman examinations.

2. The CPT does not define comprehensive history and comprehensive examination apart from the E/M guidelines. As a result, there are no definitions in the CPT of these terms as they apply to preventive medicine services and well-woman checks.

So, how do you code for the well-woman examination? This question can be answered by looking at a typical clinical scenario, says Melanie Witt, RN, CPC, MA, program manager for the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG). A patient makes an appointment for an annual gyn exam, which includes a review of her lifestyle and recent health history, obtaining a weight, a blood pressure check, and a thorough physical examination by a physician or nurse practitioner. A Pap smear is taken, but neither the discussion with the patient nor the physical examination reveals any signs of disease. How should this be coded?

First, says Witt, coders must remember that a well-woman examination is coded as a preventive service, not as an office visit. Second, she says, the E/M guidelines have nothing to do with preventive services. Therefore, while a well-woman check is a comprehensive history and examination, it is not regulated by the definitions of comprehensive history and comprehensive examination in the E/M guidelines.

The distinction here is that an office visit for a new or established patient must be motivated by a sign of illness or a symptom for which the patient is seeking medical attention. Commonly referred to as the history of present illness (HPI), this includes a chronological description of the development of the patients illness from the first signs and symptoms to the day of the office visit.

In the case of a well-woman exam as described above, there is no HPI. The patient is seeking medical attention for preventive services only. In this case, then, the proper codes for these routine checks are the preventive medicine services codes 9938499387 for new patients and 9939499397 for established patients. Simply define whether the patient is new or established, determine her age, and code according to the level of service provided.

Documentation for Comprehensive Preventive Exams

Now that you have the code, you need to make sure that you have the documentation in the patients chart to back up the code you have selected. But, as we suggested earlier, the CPT code does not define precisely what should be included in the comprehensive history or the comprehensive examination that are rendered as part of the preventive medicine service. Instead, the CPT says that, The extent and focus of the services will largely depend on the age of the patient.

In lieu of specifics in the CPT guidelines, we asked Witt for ACOGs definition of a comprehensive history and comprehensive examination as they might be applied to preventive medicine services.

ACOG replied with the following:

A comprehensive history is a complete, general patient history that considers past, family and social medical history. In this sense, it is similar to that defined by the E/M guidelines. The difference, however, is that in the preventive medicine services arena, the comprehensive history is of general concern, and is not problem-focused.

A comprehensive preventive examination performed on an adult female is also general, and may cover the following areas, according to ACOG:

Head & Neck: Thyroid, evaluation for tenderness of palpable mass

Vital Signs: Weight and blood pressure

Breasts: Evaluation of symmetry, hair distribution, nipple discharge. Palpable masses or lumps, tenderness, axillae

Back: Evaluation of the costo-vertebral area for tenderness or palpable mass

Abdomen: Evaluation of the contour, organomegaly, tenderness, palpable mass, rigidity, palpation of abdominal contents

External Genitalia: Evaluation of general appearance, hair distribution, the Bartholin and paraurethral glands, labia majora and minora, clitoris and hymenal ring, lesions, introitus

Vagina: Evaluation of general appearance, estrogen effects, discharge, lesions, pelvic support (cystocele, rectocele)

Cervix: Evaluation of general appearance, lesions, tenderness, consistency, mobility, position, discharge

Uterus: Evaluation of size, contour, position, mobility, tenderness, consistency, descent (support)

Adnexae/parametria: Evaluation of palpable mass, tenderness, organomegaly, nodularity

Rectal: Inspection of anus and perineum, evaluation of palpable mass (rectovaginal), stool, tenderness

This examination, which is what most physicians would consider to be a comprehensive examination for a female patient, says Witt, is the one that ACOG originally proposed when HCFA was developing its E/M definitions. Coders should note that it includes examination of areas of the body other than the female genitourinary tract.

Remember that the provider can use his or her discretion when performing this examination, and HCFA does not require that certain elements are included in preventive medicine examinations. Provider discretion means that a well-woman examination for a sexually active woman in her 30s may be very different from that performed for a young pre-menarche adolescent who is not sexually active.

Office Visit Codes

To review, E/M guidelines apply only to office visits for patients that seek medical attention for a specific medical problem. To code for office visits using the E/M guidelines there is no difference between the definition of comprehensive history in the 1995 and 1997 versions.

However, prior to 1997, a comprehensive examination was defined as a general multi-system examination (eight or more findings about the 12 organ systems) or a complete examination of a single organ system. However, the single organ system examination was not described in detail.

The 1997 guidelines removed much of the room for interpretation, since HCFA pinpointed precisely what components were required to qualify for a comprehensive examination of a single system. The complete definition of a female genitourinary system examination is listed below.

A comprehensive female genitourinary examination, according to the 1997 guidelines, should include all elements in the box on page 28 identified with an asterisk. In addition, providers should document every element in the categories of Constitutional, Gastrointestinal and Genitourinary as well as at least one element in each of the other categories.

With the new guidelines, the doctor knows exactly what the auditor is looking for, Witt says. You have the advantage of little room for auditor interpretation. The single system exam is clearly defined.

The option of using either the 1995 or 1997 version of the guidelines, at this point, remains with the individual practice. As long as coders are consistent, they are in compliance with the law. And, regardless of the choice, with documentation, its always best to err on the side of thoroughness and to document both the history and the examination as completely as possible. As the old saying goes, its better to be safe than sorry.

Elements of a Female Genitourinary System Examination System/Body Area Constitutional * Measurement of any three of the following seven vital signs: 1. Sitting or standing blood pressure, 2. Supine blood pressure, 3. Pulse rate and regularity, 4. Respiration, 5. Temperature, 6. Height, 7. Weight * General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming) Neck * Examination of neck (e.g. masses, overall appearance, symmetry, tracheal position, crepitus) * Examination of thyroid (e.g. enlargement, tenderness, mass) Respiratory * Assessment of respiratory effort (e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement) * Auscultation of lungs (e.g. breath sounds, adventitious sounds, rubs) Cardiovascular * Auscultation of heart with notation of abnormal sounds and murmurs * Examination of peripheral vascular system by observation (e.g. swelling, varicosities) and palpation (e.g. pulses, temperature, edema, tenderness) Gastrointestinal * Examination of abdomen with notation of presence of masses or tenderness * Examination for presence or absence of hernia * Examination of liver and spleen * Obtain stool sample for occult blood test when indicated Genitourinary * Inspection and palpation of breasts (nipple discharge, masses or lumps, tenderness, symmetry) * Digital rectal examination, including sphincter tone, presence of hemorrhoids, rectal masses * Pelvic examination, with or without specimen collection for smears and cultures, including: External genitalia (general appearance, hair distribution, lesions) Urethral meatus (size, location, lesions, prolapse) Urethra (masses, tenderness, scarring) Bladder (fullness, masses, tenderness) Vagina (general appearance, estrogen effects, discharge, lesions, pelvic support, cystocele, rectocele) Cervix (general appearance, lesions, discharge) Uterus (size, contour, position, mobility, tenderness, consistency, descent or support) Adnexae/parametria (masses, tenderness, organomegaly, nodularity) Anus and perineum Lymphatic * Palpation of lymph nodes in neck, axillae, groin and/or other locations Skin * Inspection and/or palpation of skin and subcutaneous tissue (e.g. rashes, lesions, ulcers) Neurological/Psychiatric * Brief assessment of mental status including Orientation (e.g. time, place and person) and Mood and affect (e.g. depression, anxiety, agitation)