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Ob-Gyn Coding Alert

How Much Does a Simple Pre-Op Exam Mean to You?

Published on Sun Feb 01, 2004

Using the proper code can make you $200 per week

You could be missing the perfect opportunity to use the higher-paying consultation codes (99241-99245).
 
If a surgeon requests your ob-gyn's opinion regarding surgical clearance for a patient, the preoperative exam or service qualifies as a consultation if the ob-gyn documents the reason for the request and issues a report of his findings to the requesting surgeon.

Get an Extra $38 With 99242

Many practices are losing this deserved revenue because they're reporting an office visit, such as 99213 (Office or other outpatient visit for an established patient ... 15 minutes face-to-face) or 99214 (... 25 minutes face-to-face). But the consultation codes, for instance 99242 (Office consultation for a new or established patient ... 30 minutes face-to-face) and 99243 (... 40 minutes face-to-face), reimburse at a much higher rate.
 
In fact, 99213 reimburses approximately $38 less than its consultation equivalent 99242, based on national Medicare allowances. Because the ob-gyns do the work for a consultation, they should be paid for it.

99213 and 99242 Require Similar Elements

Despite the revenue disparity, 99213 and 99242 basically require the same elements. The difference is that 99213 requires only two of the three key components - expanded problem-focused history, expanded problem-focused examination, and/or low-complexity medical decision-making, says Judy Richardson, RN, MSA,
CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. CPT specifies the same history and examination requirements for 99242 but allows straightforward medical decision-making.
 
But remember, 99242 requires the provider to document all three components, says Mary Mulholland, BSN, RN, CPC, a reimbursement analyst for the office of clinical documentation at the University of Pennsylvania's department of medicine in Philadelphia.
 
For example, a general surgeon requests that an ob-gyn clear a 35-year-old ob patient in her first trimester for gallstone surgery. The general surgeon wants to make sure he can safely perform surgery without risk to the patient or her fetus. The ob-gyn performs an expanded problem-focused history, expanded problem-focused examination and straightforward medical decision-making.
 
This preoperative exam would qualify for either 99213 or 99242. But in this situation, you should choose 99242 for the ob-gyn's service. On the other hand, if you choose the office visit code (99213, which contains 1.42 relative value units [RVUs] and reimburses $53.02) instead of the consultation code (99242, which has 2.45 RVUs and pays $91.48), you will cost your practice $38.46 per visit, based on the Medicare Physician Fee Schedule.
 
On average, ob-gyns perform four to five preoperative exams per week, some experts estimate. Consequently, if you're using 99213 instead of 99242, you may be sacrificing nearly $200 in revenue per week.

Look Closely at Chief Complaint and Findings

To gain this ethical extra revenue, make sure the visit meets the three R's of a consultation. Use a consultation code when the patient's medical record shows:
 

  •  the surgeon requested the ob-gyn's opinion
     
  •  the reason for the request
     
  •  a written report to the surgeon describing the
     ob-gyn's findings.

    The three R's may not always be in the same place in the physician's record. The ob-gyn usually documents the first two items in the patient's chief complaint (CC). The reason for the encounter - the CC - is why the surgeon asked the ob-gyn to perform the preoperative exam.
     
    For instance, the ob-gyn notes, "Ms. Jones seen at the request of Dr. Smith, who is requesting preoperative clearance due to gallstones." This statement shows who requested the ob-gyn's opinion and the reason for the request. This will help the payer see that the ob-gyn's exam is medically necessary. The general surgeon requests the ob-gyn's opinion concerning whether the patient's pregnancy will affect the surgery.
     
    The ob-gyn must issue a written report of his findings to the surgeon, stating that in his opinion the patient is fit to undergo the inherent risks of surgery and anesthesia. Look for the ob-gyn's findings under "impression" and "plan" in the medical record for this information.
    Medical Necessity Can Be the Key

    In addition to the three R's, to accurately report this service to the carrier, the ob-gyn must identify the medical necessity for the service, Mulholland says. "The provider must report the appropriate ICD-9 codes."
     The physician should list the primary service first - for example, V72.83 (Other specified preoperative examination) - followed by the diagnosis code(s) identifying the condition(s) that required evaluation (such as 574.20, Calculus of gallbladder without mention of cholecystitis; without mention of obstruction), Mulholland points out.
     
    You should remember that the diagnosis code(s) you use describes the reason for the consult, that is, pregnancy and not the diagnosis the surgeon is using. "A very quick way to receive a denial for your consultative services is to use the same diagnosis as the surgeon," Richardson says.

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