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Ob-Gyn Coding Alert

Reader Question:

Ask, Does Patient Have Gynecological Concerns?

Published on Wed Nov 07, 2007

Question: We are a cancer center with various departments including one in which the doctor and his nurse practitioners (NPs) deal primarily with breast cancer. He sent an established patient upstairs to the second floor to our gynecologist/oncologist department to see an NP for a pap smear. She usually does a full unclothed exam, pelvic and rectal. She reports these with 99213-99214 and V76.2. Is her coding correct? South Carolina Subscriber Answer: No, you should report this visit as a preventive medicine service with 99395-99397 (Established patient preventive medicine service) and V72.31 (Routine gynecological examination). This diagnosis code represents the nature of the exam with or without collection of a Pap smear specimen. The patient does not have any gynecological concerns, and the NP is not treating breast cancer. Therefore, you should not report a problem-related office visit using 99213-99214 along with V76.2 (Special screening for malignant neoplasms; cervix).
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