Ob-Gyn Coding Alert

Question: A patient is scheduled for an annual examination but presents with her menses. The ob-gyn defers the pelvic exam and does not take the Pap smear and cultures. How should I code this? And how should I report the follow-up visit when the physician performs the pelvic exam as well as the Pap and cultures?

Hawaii Subscriber

Answer: You have three choices in this case. You can report the full service (99395, Periodic comprehensive preventive medicine ... 18-39 years) at the time of the initial encounter and schedule the patient to return for the Pap smear at a later date. The second visit would be a "no-charge" visit because you have already reported the full service with the initial visit. On the other hand, you can bill for the full service when the patient returns to complete the exam.

Alternatively, you can report the annual exam code appended with modifier -52 (Reduced services) and then bill a low-level E/M service (for example, 99212, Office or other outpatient visit for the evaluation and management of an established patient ) when she returns. This low-level E/M code will capture the ob-gyn's efforts when he or she collects the Pap smear and cultures (if any).

If the physician addresses other patient concerns in addition to performing the Pap smear during the second visit, this may increase the E/M service level. Be sure to check the doctor's documentation to determine if this is the case.