Ob-Gyn Coding Alert

When an adolescent patient who is 12 to 17 years old sees a gynecologist, the visit can be more complex and often can take more of the physician's time than an adult woman's visit.

Coding these exams correctly and gaining optimal reimbursement depends on several factors, including billing for time spent counseling, billing for prolonged services, if appropriate, and documenting services provided during problem visits. Know What 99384 and 99394 Include If an adolescent is seeing the gynecologist for a wellness exam and does not have a chief complaint, CPT specifies that you should report 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; adolescent [age 12 through 17 years]) for new adolescent patients.

For established 12- to 17-year-old patients, report 99394 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; adolescent [age 12 through 17 years]), according to CPT. If the patient is new and 18-39 years of age, use 99385 for an initial preventive medical evaluation. Report 99395 for established patients 18-39 years of age. Keep in mind that 99384 and 99394 include documentation of "an age and gender appropriate history," which for adolescents will likely include information on menstruation and sexual activity. Indeed, adolescent morbidities center on patients'behaviors and life situations, so physicians must put more effort into collecting information in those areas for adequate health assessments, says Robert Brown, MD, professor of clinical pediatrics at Ohio State University College of Medicine & Public Health and head of the adolescent health department at Children's Hospital in Columbus.

Billers and physicians shouldn't assume that adolescents must have parental approval before receiving gynecological services. Federal and state laws may allow adolescents to receive services related to reproductive health and sexually transmitted diseases (STDs) without parental consent, Brown emphasizes.

Counseling an adolescent for "risk factor reduction intervention," such as instructions for birth control and prevention of STDs, is a component of preventive wellness codes and should not be billed separately, says Michael L. Berman, MD, FACOG, FACS, professor in the department of obstetrics and gynecology at the University of California, Irvine. In addition, codes 99384 and 99394 include a breast exam and pelvic exam as part of the comprehensive multisystem exam. If the adolescent has a Pap smear, the specimen collection is part of a preventive medicine or office visit (99201-99215), and you would not report it separately.

Use the appropriate V code as the diagnosis code and link it to the [...]