Ob-Gyn Coding Alert

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 [...]