Ob-Gyn Coding Alert

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.