Ob-Gyn Coding Alert

Question: A patient comes into our office for her annual exam. She is on birth control pills and hormone replacement therapy and has no new complaints. Her prescription for birth control pills and hormones is renewed for the year. Is this an established patient visit or well visit?

Jenie Graham, RRA, CCS
Ob & Gyn Specialists, PC, Davenport, Iowa

Answer: When coding for any service, you must ask yourself, What is the reason for the patients visit today? Patients on birth control pill or hormone replacement therapy usually are given these medications for prophylactic or preventative reasons. Therefore, for annual checkups (established patient), you would use the preventive medicine codes representing the patients age commonly 99394-99397 (periodic preventative medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient) for gyn patients.

Also note that part of the description of the service is risk factor reduction interventions. This is where birth control and hormone replacement therapy would come into play. Keep in mind that the intent of age-based codes is clarify that not all examinations fall under the same type of history, exam and other contributory factors for each age group. The ICD-9 code must correctly identify the reason for the visit as well. For instance, if the patient presents for a routine gyn exam and renewed prescription of hormone replacement therapy, you would include V07.4 (postmenopausal hormone replacement therapy).

A patient having problems with her medication for instance, a menopausal patient comes to the office complaining of hot flashes while taking 0.5 mg of estradiol daily would constitute a problem-oriented evaluation and management service. To indicate medical necessity, you would assign 627.2 (menopausal or female climacteric states).

Answered by Laurie Castillo, MA, CPC, president of Physician Coding and Compliance Consulting in Manassas, Va.