Ob-Gyn Coding Alert

Dont Let Time and Reimbursement Slip Away When Reporting Adolescent Exams

Published on Tue Apr 01, 2003

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 preventive service to let the laboratory know the reason for the Pap smear interpretation. Likely Vcodes for Pap smears collected during adolescent exams include V72.3 (Special investigations and examinations; gynecological examination) and V76.2 (Special screening for malignant neoplasms; cervix).

Use Modifier -22 to Report Exceptional Services

One strategy for capturing the extra work involved in adolescent wellness exams is to append modifier -22 (Unusual procedural services) to 99384 or 99394 when the physician provides services that are unusual or otherwise significantly different from those provided during wellness checks for adult women.

Often, a preventive health visit for a sexually active adolescent may take 15-25 minutes longer than for a sexually active adult and may require more provider time than a non-sexually active adolescent visit, says Melanie Witt, RN, CPC, MA, an independent ob-gyn coding and documentation educator based in Fredericksburg, Va.

For a young patient unaccustomed to pelvic exams, for instance, the physical examination may require more provider time, Berman observes. Likewise, counseling for birth control and STD prevention may take longer because the patient or an accompanying parent may have lots of questions or concerns, coding experts confirm.

For example, a preventive health visit for a new 15-year-old non-sexually active patient may take 45 minutes. A new preventive health visit for a sexually active adolescent, on the other hand, may require an additional 25 minutes given the complexities of the issues surrounding sexuality, Witt says.

The physician may be able to bill for the 25 minutes by adding modifier -22 to 99384, Witt says. You would also report diagnosis code V72.3 (Annual routine examination). To support billing modifier -22 for the extra time, documentation must include information regarding special services provided, such as extra time spent conducting an exam or discussing birth-control methods.

And, modifier -22 would be appropriate for preventive care visits that take longer when the adolescent patient has a physical or developmental disability, Witt says.

Reserve Modifier -25 for Problem Visits

Frequently, an adolescent will come for a wellness exam but will have several problems that she wants to discuss with the physician, or the physician may discover a problem during the exam.

CPT specifies that when "an abnormality is encountered or a pre-existing problem is addressed" during the wellness exam, and the problem is "significant enough to require additional work," you should report the appropriate office visit code (99201-99215) and the preventive medicine services code (99384 and 99394).

You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or service) to 99201-99215 to indicate that the physician performed a separate service in addition to the preventive medicine service, according to CPT.

For instance, if a gynecologist detects a cervical polyp on a 16-year-old patient during a wellness exam and removes the polyp, you would report the appropriate E/M service (99201-99215) and the procedure for removing the polyp, Berman advises. Attach modifier -25 to the E/M service code, indicating the physician performed a separate service at the time of the exam, he adds.

If the physician bills two separate E/M codes, make sure the documentation clearly indicates that he or she performed significant, separate services, Witt says. Look for descriptions of the services performed during the wellness exam and any separate, problem-oriented diagnoses, such as the polyp detection and removal in the example above.

Bone Up on Payer's Dual Coding Rules

Some third-party payers will accept both a preventive and problem visit code on the same day, but others will not, so it's best to check individual payer guidelines, coding experts stress. You should also make a list of third-party payers that accept both codes and those that do not.

For instance, when a new 17-year-old patient comes in for a wellness exam and the physician detects a problem such as vaginal discharge (623.5), you would report the following codes if the payer does accept both preventive and problem visit codes on the same day, Witt says:

99384 (new patient preventive care) linked to V72.3

9920x-25 (new outpatient visit) linked to ICD-9 623.5 (vaginal discharge).

Note that you should select the E/M code based on the level of history, examination and medical decision-making required to evaluate the vaginal discharge.

If the insurer will not accept both codes, however, the provider has two options: (1) see the patient at separate visits or (2) bill for the segment of the visit that took more than 50 percent of the time, Witt says.

For instance, in the example above, if over 50 percent of the time involved preventive care, report 99384-22, Witt says. List the diagnoses as V72.3 first, since the primary reason for the exam was an annual checkup, and 623.5 second, she says.

If assessing the vaginal discharge took more than 50 percent of the time, however, report 9920x for the new outpatient visit, and link it with 623.5 as the first diagnosis and V72.3 as the second. Moreover, you can bill for the additional work during the new outpatient problem visit with a prolonged service code such as +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...; first hour [list separately in addition to code for office or other outpatient evaluation and management service]), as long as the documentation describes why the prolonged services were necessary. (See "Test Yourself" in article 16 for more information concerning prolonged services codes.)

Remember: You cannot report modifier -22 with problem visits that are prolonged, because these visits already have a time component. Instead, you should use prolonged service codes to report the additional time.

Note: If you have questions regarding billing adolescent gynecological services, e-mail the American College of Obstetricians and Gynecologists'(ACOG) Coding and Nomenclature Department: coding@acog.org. You also can visit ACOG's Web site, www.acog.org, for general information on adolescent gynecology.