Ob-Gyn Coding Alert

Ob/gyns order a wide variety of tests for their patients, ranging from Pap collection to urinalysis and cholesterol screenings. Some tests are sent to outside labs for analysis and reporting, others are interpreted "in-house." Knowing which tests or which portions of test fees can be billed by the practice and which tests are billed by the outside laboratory can help circumvent an audit, inappropriate billing or accusations of fraud. Likewise, adherence to CLIA certification rules will keep a practice up-to-date with current regulations.

In-House Versus Outside Tests
The most common test ordered in ob/gyn practices is a urinalysis to check for pregnancy. The most frequently administrated urine pregnancy test is 81025 (urine pregnancy test, by visual color comparison methods), yet 84703 (gonadotropin, chorionic [hCG]; qualitative) is also reported often. Results are almost immediate for both of these tests, and there is no need to send the specimen to an outside laboratory. The same is true for tests such as wet mount or KOH slide (87210, smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]), fecal occult tests (82270, blood, occult, by peroxidase activity [e.g., guaiac]; feces, 1-3 simultaneous determinations) and checking for vaginal pH (82120, amines, vaginal fluid, qualitative).
 
However, many ob/gyn offices lack the proper equipment and staff to conduct tests that are more advanced than those mentioned above. These tests include Pap-smear interpretations, blood panels and quantitative hCG tests for pregnancy. For these tests, specimens drawn in the office are sent to an outside laboratory for evaluation, and the results are returned to the practice, reviewed by the physician and reported to the patient. Therefore, the practice is responsible for one aspect of the test, and the pathology lab is responsible for the other.

Who Does the Work?
When tests are drawn at the ob/gyn office, they are often done in conjunction with an E/M visit or a regularly scheduled well-woman visit. Unless they are a nonroutine addition to a "normal" visit, the taking of the test specimen is frequently not paid by the insurer. In other words, if a Pap smear is widely regarded as a standard portion of a well-woman visit, the practice cannot bill the patient or her insurance company for obtaining the smear.   

But if a patient shows up for her well-woman visit (9939x, periodic preventive medicine ...) and also complains of dizziness and fatigue, the physician may order a series of blood tests. Because drawing blood is not a routine part of well-woman care, the blood draw can be billed with 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). Most blood tests and other workups are often too complex for in-house ob/gyn labs, therefore, these [...]