Ob-Gyn Coding Alert

Question: Are we supposed to use modifier 25 only when the ob-gyn performs procedures with global periods? For instance, until now, we have been using 99204-25 plus 76817 with diagnosis V22.1 for the first visit. Are we correct?


Arizona Subscriber

Answer: When you use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), you-re telling the payer that the E/M is separate and significant from the procedure or service performed at the same time.
 
Historically, payers considered diagnostic tests exempt from this (like lab and radiology), but nowadays they seem to want to know that the radiology service and the E/M are not related (that is, the purpose of the visit was not just the ultrasound, and the ob-gyn documented a separate E/M). 

But in your case, the first visit -- once you have confirmed pregnancy -- is part of the ob global package, which is a different issue. You should not be billing 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) for the first ob visit -- unless the payer requires you to itemize each visit. You should consider the visit when your ob-gyn confirms the patient's pregnancy (outside the global ob package) only a low-level service. The global ob package requires your ob-gyn to perform a comprehensive exam and history.

You may certainly bill for the ultrasound, however. If you use a diagnosis of V22.1 (Supervision of normal pregnancy), you are indicating that the ultrasound (76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal) was routine. In other words, your ob-gyn does this on all patients. Being routine may affect coverage. If the physician was screening for something specific, you should use the antenatal codes (V28.x, Encounter for antenatal screening of mother).