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 will not qualify as consultations. Coding as an outpatient service (99201-99205, office or outpatient visit) can be appropriate when the payer has indicated that admission to a mental facility is not an inpatient service.

Thomas Kent, CMM, Kent Medical Management in Dunkirk, MD, explains. The ob/gyn could be called in thinking this will be a preventative-care visit. But if during the course of the patient history and exam, the patient expresses a complaint or problemand I imagine that perhaps one third of all patients wouldthe visit might be considered an outpatient service by some payers.

The reason outpatient services codes might work is because the ob/gyn may take over treatment of the specific problem, not just simply alert the admitting physician to the problem or complaint.

Witt explains, The only way a legal requirement for a Pap smear and mammography could be considered an outpatient visit is if the admitting physician asked the ob/gyn to take over care, and that care was needed because a problem was found or complaint expressed that required the ob/gyn to perform an evaluation and management service involving that complaint.

Still, Witt adds that some payers may classify such an encounter as subsequent hospital care rather than an outpatient service because of the location of the patient.

Preventive Services Code Usually the Best Fit

The experts consulted agreed that the case in question most likely falls within the realm of preventative medicine (99381-99387 [initial preventive medicine]) and should be coded based on the age of the patient. This assumes that the patient is new to the ob/gyn; codes 99391-99397 would apply for an established patient.

Witt says, These codes also require that a comprehensive history and comprehensive exam be performed that is appropriate to the patients age. Although the physician in this case only did a detailed history, since he or she performed a comprehensive ob/gyn exam and documented the admitting information, I would think the conditions for using this code are met.

Witt explains that a preventive service also may include counseling the patient about issues related to the patients age. If the physician also has to address a minor problem at the time of the preventive service, that too would be part of the exam and not coded separately, says Witt.

However, Mary Thomas, coding coordinator for Physicians Clinic, a multispecialty doctors group in Omaha, NE, is skeptical that all insurers would pay for the service as preventative care. For Medicaid, says Thomas, coding for preventive medicine would probably be allowed. (Especially since Medicaid is a state-funded program in the very state whose law requires that the service be provided.) But for private insurers, Thomas continues, the claim could very well be rejected.

Thomas has had similar claims rejected for services that the insurers argued were out of place in a mental facility. In those cases, says Thomas, we had to provide documentation that we did perform the service and that we were required to do so by law. Thomas suggests submitting, along with the claim, a copy of the statute mandating the offering of Pap smears and mammography.

Fewer Problems if Modifier -32 Used

Thomas Kent offers a sound alternative for avoiding denials. He suggests that in coding for any of the scenarios discussedconsultation, inpatient or outpatient services, or preventive carethe use of the
-32 modifier (mandated services) will help deter denials or questions on the claim. Coders should note that the language of modifier -32 has been expanded in CPT 2000, but essentially, it is defined as Mandated Services ... related to mandated consultation and/or related services (e.g., PRO, third-party payer, governmental, legislative or regulatory requirement).

Kent says that years ago, the -32 modifier meant you got paid at the full schedule. Thats not true anymore, but it does mean that you will run into fewer problems with the claim. It removes the question of medical necessity.

Ideally, with several states having similar requirements to Marylands, one of these options will work, particularly with modifier -32 attached. If these approaches fail to generate reimbursement, the next step might be to contact the state insurance commissioner to appeal a payers negative decision.