Ob-Gyn Coding Alert

Question: When a colposcopy is performed at the same time as a new patient visit, what is the appropriate way to bill? Can we bill the E/M visit with the colposcopy and, if so, is a modifier necessary?

West Virginia Subscriber

Answer: Colposcopy (57452) involves the examination of the vagina and cervix using an instrument called a colposcope. From a strictly coding perspective, you can bill both the colposcopy and an E/M service on the same date as long as your documentation supports this. In most cases with a new patient, there will be an initial evaluation of complaints followed by a decision to perform the testing.

If the physician suspects a problem and decides to do the colposcopic exam in addition to a manual exam, then both can be billed. Make sure the colposcopic exam and the reason for doing it are also documented. You will need to add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code you bill to indicate that it was separate and significant from the colposcopy performed at that visit.

Keep in mind, however, that not all payers will allow this combination of services. If the payer considers colposcopy to be just another way to perform an examination of the pelvic structures, they may decide to pay only the E/M service even when you use modifier -25.