Ob-Gyn Coding Alert

Question: A new patient comes to the office for her annual exam. While talking to the patient, the provider finds out she went to her primary care physician (PCP) two weeks earlier for a routine early exam that included a Pap smear and pelvic exam. But the PCP was unable to insert the speculum for the Pap and told the patient to see an ob/gyn. Our ob/gyn performed a breast exam, a pelvic exam and a Pap, but nothing else. Should I bill this as preventive care or use a lower-value code?

New Mexico Subscriber

 
Answer: Bill this as a preventive service, assuming that your physician took a comprehensive history and also provided counseling/risk-factor reduction interventions for the patient. If not, you can bill the preventive service (9938x, depending on the patients age) with modifier -52 (reduced services) appended.