Ob-Gyn Coding Alert

Reader Question:

Report Wet Mounts Separately

Question: Are wet mounts bundled into E/M services? For example, a patient presents with foul odor with vaginal discharge. The ob-gyn performs a wet mount and diagnoses bacterial vaginosis. Washington Subscriber

Answer: You can usually bill the wet mount separately from the E/M service. Normally, you would not 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 because the laboratory service is not a procedure. For example, you would report the appropriate-level E/M service (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ). In addition, for private payers, you would bill a wet-mount code, such as a saline prep to evaluate the patients condition, using 87210 (Smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]). For Medicare, you would report the wet mount using a HCPCS codes (for instance, Q0111, Wet mounts, including preparations of vaginal, cervical or skin specimens). Remember, though, that you can bill for a wet mount only if you have a correct Clinical Laboratory Improvement Act (CLIA) waiver. This is a federal regulation having to do with your practice being authorized to perform this level of lab test.    
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Ob-Gyn Coding Alert

View All

Which Codify by AAPC tool is right for you?

Call 844-334-2816 to speak with a Codify by AAPC specialist now.