Ob-Gyn Coding Alert

Question: A patient who has had the Pap smear done by another practice was referred to our office for colposcopy. What are the right codes and modifier to use?

Maryland Subscriber

Answer: If the patient had symptoms and your physician needed to evaluate her prior to deciding that colposcopy was warranted her case, use 57452 (Colposcopy of the cervix including upper/adjacent vagina) or 57455 (....; with biopsy(s) of the cervix) as well as any one of the E/M new patient codes (99201-99205, Office visit for the evaluation and management of a new patient...). Append modifier 25 (Significant, separately identifiable evaluation and management service on the same day of a procedure or other service) to the E/M code.

If the patient presents solely for the procedure, then don't bill the E/M code and the modifier. CPT guidelines make it clear that the E/M service must be separate and significant from the procedure. You should note that Medicare rules state that you should include the decision to do a minor procedure in the procedure itself. If you have a payer that follows those rules, you should not report a separate E/M.

Strategy: If you used modifier 25 correctly, it can generate extra revenue. The key is to recognize when your physician's extra work is "significant," and therefore, additionally billable. Asking the following questions may lead you to the right answer (if you answered "yes" to all of them):

• Did your physician perform and document the key components of a problemoriented E/M service for the complaint or problem?

• Could the complaint or problem stand alone as a billable service?

• Is there a different diagnosis for this portion of the visit?

• If the diagnosis will be the same, did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.