Ob-Gyn Coding Alert

If the patient sees an ob-gyn just for counseling and does not have an established illness, you should use one of four codes. Depending on the session’s duration, assign:

According to CPT®, counseling codes apply when a physician counsels on family problems, diet and exercise, substance abuse, sexual practices, injury prevention, dental health, and diagnostic and laboratory test results available at the time of the encounter.

 

Caution: In other words, the purpose of the visit must be promoting health and/or preventing illness or injury. If the patient is ill, you shouldn’t use the preventive counseling codes. For example, use a counseling code when the doctor provides counseling on diet and exercise for a well patient who wants to lose weight, but not when the doctor provides the same services to a diabetic patient.