Ob-Gyn Coding Alert

Question: A 17-year-old established patient who was not using birth control recently saw our gynecologist for emergency contraception the day after having unprotected sexual intercourse. He performed a medical exam and then counseled the patient for 15 minutes. He prescribed one 75-mg tablet of levonorgestrel to be followed in 12 hours by one additional tablet. How should I code this?

Michigan Subscriber

Answer: The service described is an E/M service. Although the ob-gyn counseled the patient for 15 minutes, for you to choose the E/M service code based on time instead of the key components of history, exam and medical decision-making, both the total time and the counseling time have to be documented in the record. This is because CPT states you may default to counseling time when that activity dominates the visit. If the physician did not perform an exam, and documented the counseling's content, 15 minutes would equate to 99213 (an expanded problem-focused service that typically takes 15 minutes of physician face-to-face time).

Because the physician performed an examination, the documentation must contain both the total time with the patient and the amount of time spent counseling to determine whether counseling represented the major part of the service. If the patient was seen on an emergency basis during regular office hours at a time normally reserved for same-day appointments, report 99058 (Office services provided on an emergency basis) in addition to the E/M code. The diagnostic code for this service is contraceptive management in this case, V25.8 (Other specified contraceptive management) would probably be the best code to use because you are giving the patient the pill after the fact.