Reader Question:
Well Woman Examination
Published on Mon Jan 01, 2001
Question: An established Medicare patient presents at the clinic for a well woman examination, which includes a breast exam and a Pap smear. The patient is eligible for a Pap smear her last one was 3 1/2 years ago. During the exam a polyp is located on her cervix and the doctor makes the decision to perform a biopsy of the polyp. When coding this visit is it acceptable to bill as follows:
99386-QB the diagnosis is V76.2
G0101-QB the diagnosis is V76.2
99203-25-57 the diagnostic codes are 622.7 and 626.0
57454-QB the diagnosis is 622.7.
CPT guidelines suggest that an evaluation and management (E/M) visit can be billed along with the preventive medicine exam code, but Ive never understood it this way from previous instruction. Are we coding correctly?
Rhonda Barber
Perryville Family Care Clinic, Perryville, Mo.
Answer: CPT allows coding for both a problem and preventive E/M service at the same encounter and also states that you can bill for a problem E/M service and a procedure on the same day. However, the documentation must clearly show that the problem E/M service was separate and significant from the preventive service or the procedure. For example, in order to bill 99203 (office or other outpatient visit for the evaluation and management of a new patient ...), the documentation must show a detailed history, detailed exam and low-complexity medical decision-making concerning only the polyp, but you cannot count history and examination elements already done as part of the preventive exam.
In this case, you are suggesting coding for two parts of a preventive service a problem E/M service and a procedure at the same encounter but this is overcoding. In the absence of knowing what was documented in the medical record, it would seem more likely that the patient would not have complained of symptoms that led to the discovery of the polyp, but rather this was an incidental finding at the time of the preventive visit. If this is so, a problem E/M service would not be billed in addition to the preventive services. Your documentation must also show a separate and significant E/M service when a procedure is billed at the same encounter, and if the major service following the discovery was its removal, it is unlikely the documentation is in place.
If you believe that a separate and significant E/M service was documented in the record (separate from both the preventive service and the procedure) you can certainly bill for it, but the only modifier you would apply is modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier -57 (decision for surgery) is [...]
