Ob-Gyn Coding Alert

Proper coding and good documentation are crucial to obtaining fair reimbursement when a physician provides services mandated by law. Without them, payment is likely to be denied.

For example, Maryland law requires that female patients admitted to a mental health ward be offered a Pap smear and mammography. While the law only mandates those two services, most physicians agree that a comprehensive gynecological or well-woman exam is the standard of good care. Thus, the ob/gyns documentation of seeing such a hospitalized mental health patient should include a detailed history, a review of the admitting exam and a comprehensive gynecological exam that includes a Pap smear collection.

Finding the Right Definition and the Right Code

At first glance, the proper CPT code for the above-described session would appear to be 99251-99255 (initial inpatient consultation for a new or established patient [the exact code depends on depth of patient history recorded, detail of examination and degree of medical decision-making]). But the fact that the offer of a Pap smear and mammography is required by law complicates the situation and makes it less straightforward than it may initially seem.

Melanie Witt, RN, CPC, MA, and program manager for the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists (ACOG) says that a consultation is a specific kind of evaluation and management service that requires certain criteria be met before it can be billed. For starters, the consulting physician must have been asked for his or her opinion by another physician.

But in the situation described, the consulting physician was asked to examine the patient not because a second opinion was sought by a requesting doctor, but because the examination is mandated by law. The visit is considered a consultation only ifapart from being a legal requirementthere is a medical reason to conduct the Pap smear. Otherwise, says Witt, It would be hard to show that a consultation was appropriate for a patient who is otherwise healthy and for whom no problems were suspected.

In a case where there is a medical necessity and a requirement for legal compliance, the following three criteria must be met to support billing for a consultation:

1. The request needs to be documented in the medical chart in case the consulting
physician is audited and the requesting physicians documentation does not indicate a
consult was requested.

2. The consultant must document the advice or opinion requested.

3. The consultant must inform the requesting
physician about the advice or opinion in writing. This
could mean a letter to the physician (strongly advised by
most healthcare attorneys) or a complete notation on a
shared hospital chart.

Given these requirements, the majority of cases similar to the sample one presented [...]