Ob-Gyn Coding Alert

If a patient comes to your practice for an office visit because her left breast hurts and she feels a lump, and you perform a breast cyst aspiration, how would you code to make sure both the visit and the procedure get paid even though they occurred on the same day?

This is just one of many situations ob/gyns face when dealing with an E/M service and a procedure on the same day. To receive the optimal amount of reimbursement, the coder must measure the appropriate evaluation and management (E/M) level of service for an office visit, provide the modifier -25if an E/M service is performed in addition to a procedureand give the correct procedural code for the additional service. (For more information on determining the level of E/M service, see the next column.)

Correct Use of Modifier -25 is Key

A patient can come in for an E/M service and require a procedure on that same day, states Amy Blum, a medical classifications specialist, specializing in ob/gyn, for the National Center for Healthcare Statistics in Washington, DC. And the ob/gyn can receive reimbursement for both, as long as the patients record has the appropriate

ICD-9 codes and the modifier -25 with the E/M code.
In the above situation, you would code the procedure 88170 (fine needle aspiration, with or without preparation of smears; superficial tissue [eg, thyroid, breast, prostate]), and the office visit would be 99211-99215 (established patient) with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to the E/M code.

The diagnosis does not have to be different for both the E/M and additional procedure; CPT states, the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.

Determining Proper E/M Level of Service You are allowed only one E/M code per day, so it is best to choose that code discerningly. The level of the E/M service depends on three key components: history, examination, and medical decision making. It is worth mentioning that many physicians are still mistakenly basing this coding on time spent with the patient, rather than following the criteria set forth in the E/M section of CPT. Coding must be based on written documentation and medical decision making involved with the visit. There are four types of history (problem focused, expanded problem focused, detailed, and comprehensive), and each type may or may not include these elements (see sidebar for definitions): chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and/or social history (PFSH). The extent of the history documented depends on clinical judgment and the nature of the presenting problem(s). There are four types of examinations: problem focused, expanded problem focused, detailed, and comprehensive. Problem focused is a limited examination of the affected area or system. Expanded is the affected area plus any related areas or systems. Detailed pertains to an extended examination of the affected body area and other symptomatic or related areas or systems. Comprehensive is a general multi-system examination or complete examination of a single organ system and other related areas or systems. Based on the degree of examination, certain specific elements must be met and documented. The levels of E/M services identify four types of medical decision making: straight-forward, low complexity, moderate complexity, and high complexity. Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, measured by the number of possible diagnoses or the number of management options that must be considered; the amount or complexity of medical records, diagnostic tests, or other information that must be obtained, reviewed, and analyzed; and the risk of significant complications, morbidity, and mortality, as well as comorbidities associated with the patients presenting problems, the diagnostic procedure(s) and the possible management options. It sounds as difficult as it is; however, medical decision making is very important to quantify when choosing the level of service. Once the appropriate level has been determined for each component, an overall E/M level can be assigned. The more extensive the care is to manage the patient, the higher the E/M level. Most important, your documentation must support your codes.

Be Safe: Get Pre-authorization

Louise Grant, practice manager for Dupont Comprehensive Health Center, takes precautions when seeking reimbursement for an E/M service and a procedure on the same day by the same physician. In most cases, the insurance carriers require a pre-authorization number to receive reimbursement for this type of combination, says Grant. We usually run into problems in an emergency situation, where it is virtually impossible to fax the history, prior treatment, etc., to the insurance company before the doctor performs the additional procedure.

The office where Grant works rarely performs any procedure without a pre-authorization number. She explains, The pre-authorization is the guarantee that the insurance company approves and therefore the doctor will get paid. They do make use of the modifier -25 for E/M services the same day as a procedure but do not have a problem with payment because of the pre-authorization steps they take in advance of billing.

ICD Codes Can Also Be Crucial to Payment

To get paid for a procedure and an E/M service, make sure you have the correct ICD-9 codes, along with the modifier -25 attached to the E/M code, Blum reiterates, ICD-9 codes should match the services, i.e., a diagnosis code indicating a breast cyst should be linked to the aspiration code 88170.

In our example, the patient complained about breast tenderness (611.71, mastodynia) and a lump (611.72, lump or mass in breast), and the physician diagnoses a cyst of the left breast (610.0, solitary cyst of breast). The first two diagnostic codes will be linked to the E/M service and the third diagnosis will be linked to the procedure.