Ob-Gyn Coding Alert

Question: A new 16-year-old patient had a positive pregnancy test at home. She came in with complaints of spotting for three days, but the spotting stopped two days before the visit. The gynecologist did not document any other history in the note for this visit. The exam covered her heart, chest, abdomen and pelvic area. He performed a pelvic sonogram and determined that there was no intrauterine pregnancy (IUP). The diagnosis was "threatened abortion ... rule out ectopic pregnancy." He advised the patient to return for a follow-up visit in one week to repeat the scan. What level E/M code should I use? Is the sonogram billed in addition to the visit?

Illinois Subscriber

Answer: In this case, you can report both an E/M service and the sonogram. You should determine the level of new patient visit based on the physician's documentation of the three key components: history, examination and medical decision-making. The lowest level of any one of these three components will determine the service level you can report. In this case, you have a brief history of present illness (HPI) that outlines quality, duration and severity. If you count the information about the positive home pregnancy test as a review of one system, the documentation supports an expanded problem-focused history. Counting the pregnancy test as part of the HPI or past history would mean that the history level drops to problem-focused.

Assigning the level of examination is more problematic using the information you have supplied. Under the 1997 E/M guidelines, you have the three known exam elements of heart, lungs and abdomen. The pelvic exam is an unknown because up to 11 elements can be examined (such as external genitalia, uterus, adnexa, perineum, urethra, bladder, etc.). Under the 1997 rules, a problem-focused exam is the documentation of one to five exam elements, an expanded problem-focused exam involves six to 11 exam elements, and a detailed exam would be 12 or more exam elements. The exam you have cited above would not qualify for a comprehensive examination.

Under the 1995 guidelines, the physician performed more than a problem-focused exam. Minimally, the physician examined the affected system (the genital system) and three additional body areas. Therefore, your starting point would be an expanded problem-focused examination, which involves a limited exam of the affected area, plus two to seven additional body areas or organ systems. Alimited exam of the genital system would include only some of the structures. For instance, documenting only external genitalia, vagina and cervix would constitute a limited exam. To move up to a detailed examination, the doctor would have to extend the pelvic exam that is, examine all structures.

As for determining the level of medical decision-making, the physician is still trying to rule out ectopic pregnancy. He has also ordered an ultrasound for the next visit, and risk to the patient was moderate. This combination leads to assigning moderately complex medical decision-making for this visit. The combination of an expanded problem-focused history, expanded problem-focused exam and moderate medical decision-making equates to 99202. Even if the exam is detailed, the code will still be 99202 because the history component the lowest level portion documented is the determining factor.

There is a debate among coders as to whether you should append modifier -25 (Significant, separately identi fiable evaluation and management service by the same physician on the same day of the procedure or other service) to an E/M service when billing it with an ultrasound procedure. Many payers require you to use modifier -25 only when the physician performs a surgical procedure in the office. Others want to you to use it when the physician performs any additional service during the same session as the E/M service. Consequently, you should determine what your payers expect to see, but it does no harm to add modifier -25 if you are unsure.

Note that the diagnosis coding for both the E/M service and the sonogram will be the same 640.03 (Threatened abortion; antepartum condition or complication). You would not report a diagnosis of ectopic pregnancy because the physician is still trying to rule it out. For the case you have presented, the claim would go in as 99202-25 (if the payer requires the modifier) and 76801-76828 (Ultrasound ), both linked to 640.03.