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Ob-Gyn Coding Alert

Dont Throw Away Your Ob-Gyns Time:

: Report Well-Woman Exams and Problem-Oriented E/Ms Separately

Published on Thu May 01, 2003

You could be throwing away roughly $36 every time your patient presents for a well-woman exam with an additional complaint. Keep this money in your practice by using modifier -25 and the correct diagnosis codes.

When a patient presents for a well-woman visit (for example, 99395, Periodic comprehensive preventive medicine reevaluation and management of an individual 18-39 years), she often reports additional problems. The physician can easily spend extra time and expertise with these complaints. You can get reimbursed for this extra work based on the severity of the complaint, the amount of work the physician performs during the visit, and the documentation that supports billing the additional service.

Typically, you would charge a lower-level E/M service for this type of extra work for example, 99212 (Office or other outpatient visit for the evaluation and management of an established patient). According to Medicare's 2003 Physician Fee Schedule, 99212 has 0.99 relative value units. Multiply this by CMS'conversion factor, $36.79, and your office could be losing more than $36 for each separately reportable E/M service that you may not be submitting because it took place during the same visit as a preventive service. And if the physician had documented a 99213 service, you could be losing even more money.

Ask the Right Questions

When the ob-gyn performs an unexpected service on a patient during a routine well-woman exam for example, aspiration of a breast mass (19000) reporting the extra work is fairly straightforward. You should report the code(s) for the procedure(s) performed and bill the E/M code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). But coding becomes more confusing when the patient comes in for the well woman and reports a complaint that does not involve a procedure.

If the problem is "insignificant or trivial" and does not require additional work and the key components of a problem-oriented E/M service, you should not report the extra time with an E/M code, CPT states. On the other hand, "if an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing the preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported," CPT states.

Consequently, knowing when to bill for both a well-woman service and an E/M visit and when the additional service is not significant enough to carve out requires a case-by-case evaluation by the physician and coder.

"I tell my physicians that they can bill for well-woman and a separate E/M visit if they meet certain criteria," says Judy Troy, an ob-gyn coder with 35 years of experience and surgical coding coordinator for Capital Women's Care in Silver Spring, Md. She offers the following criteria and advice:

  • Write a separate progress note for the well woman and the E/M visit.
  • Make sure you have taken all the components of the well woman out of the E/M visit and then decide if you still have a separate visit.
  • If you do not have sufficient time to do both visits, do the problem visit and then schedule the well woman after the problem has been resolved.
  • Be prepared to argue/appeal the claim because most insurance companies probably will not pay both on the first try.

    Use Examples to Know When and When Not to Bill

    The following examples provided by Troy should help to clarify any confusion about when to report the E/M service separately and when to stop at the well-woman exam.

    Example 1: A 34-year-old established patient comes in for her yearly exam. When the ob-gyn enters the examination room, the patient complains of pain in her left-lower quadrant and blood in her stool. The physician performs an extensive exam, including the Pap smear, and finds a breast mass. He orders an abdominal ultrasound and a diagnostic mammogram of the breast with the mass.

    Coding Solution: "I would report a well-woman exam (99385, Initial comprehensive preventive medicine evaluation and management of an individual 18-39 years) linked to V72.3 (Gynecological examination), and then I would add 99212-25 or 99213-25 with 611.72 (Lump or mass in breast), 789.04 (Abdominal pain; left lower quadrant) and 578.1 (Blood in stool), Troy says. The patient's additional problems, and the physician's additional work to help the patient, present sufficient reason to report the problem-oriented portion of the visit separately.

    If the ob-gyn also performs the ultrasound, you should report 76700 (Ultrasound, abdominal, B-scan and/or real time with image documentation; complete). Similarly, if he does the mammogram, submit 76090 (Mammography; unilateral). You should link each of these codes to the appropriate reason for performing or ordering the tests. Submit 76700 with 789.04 and 76090 with 611.72.

    Example 2: A 48-year-old established patient comes in for her yearly exam. After the examination, the patient complains of continued hot flashes and mood swings, even though she is now on hormone replacement therapy (HRT). The physician discusses other hormone replacement treatments for approximately five minutes, and he and the patient decide to switch to a new HRT.

    Coding Solution: As in the previous example, you should report a well-woman exam with 99396 ( 40-64 years) linked with V72.3, says Penny Schraufnagel, office manager for Ob-Gyn Center PAin Boise, Idaho. But you should not attempt to report a separate E/M service for the physician's time spent counseling the patient about HRT. "This does not appear to be sufficient extra work to warrant an additional problem-oriented E/M code," Troy says.

    Example 3: A 32-year-old new patient with an intrauterine device (IUD) comes in for a well-woman visit and claims she has heavy periods with severe cramps every two to three weeks. He informs the patient that she should undergo an outpatient hysteroscopy, dilation and curettage, and removal of the IUD. The patient has several concerns because of an immediate family history of endometrial cancer, and the doctor spends a great deal of extra time counseling the patient and discussing the treatment plan.

    Coding Solution: In this case, report 99395 for the well-woman exam linked to V72.3. In addition, you should bill 99202-25 (Office or other outpatient visit for the evaluation and management of a new patient ), Troy says. You should bill both the preventive and problem services with new patient codes because the patient is new on the date of service for both types of service.

    You should also append the new patient E/M code with modifier -57 (Decision for surgery) because the ob-gyn made the initial decision to perform surgery during this E/M visit and the payer should not bundle this service into the global period for the procedures. Be sure to link 99202 to 626.2 (Excessive or frequent menstruation), 622.7 (Mucous polyp of cervix), 625.3 (Dysmenorrhea) and V16.40 (Family history of malignant neoplasm; genital organ, unspecified), Troy adds.

     

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