Ob-Gyn Coding Alert

Question:A 21-year-old patient comes in for annual exam. She has never had intercourse and doesn't plan to in the near future. After discussion with the ob-gyn, she declines a Pap smear. The ob-gyn does not perform a breast and pelvic exam either, and the ob-gyn does not prescribe oral contraceptives. The ob-gyn did a review of systems (ROS), a history and physical (H&P), and general assessment. What would be the diagnosis and procedure for this visit? Is there even a charge?Virginia SubscriberAnswer: You should define the exam by the requirements of the patient. You should report V70.0 (Routine general medical examination at a health care facility) for this visit and link it to 99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender- appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; 18-39 years).ICD-10: When ICD-9 becomes [...]