Ob-Gyn Coding Alert

Question: Can I give two points for "independent visualization of specimen" toward an E/M level when my provider performs and interprets a wet prep and KOH?

Oregon Subscriber

Answer: No, not if you are also billing for the wet prep and KOH, which includes interpretation (87210, Smear, primary source with interpretation; wet mount for infectious agents [e.g., saline, India ink, KOH preps]).-

Wet mount: When the ob-gyn does a wet mount, he swabs the vagina, puts the sample on a glass microscope, and mixes it with a salt solution. He examines the prepared slide under the microscope and checks for bacteria, yeast cells, trichomoniasis organisms (trichomonads), white blood cells indicating an infection, or clue cells that indicate bacterial vaginosis. This involves a smear specimen for infectious agents.

KOH slide: This lab test mixes the vaginal sample with potassium hydroxide (the KOH) in addition to the salt solution. The KOH destroys bacteria and cells from the vagina, leaving yeast hyphae and spores (if present) that indicate a yeast infection.

Note: If he has ordered the tests, that will count as one point toward medical decision-making, but billing them as an independent interpretation would mean he is viewing the slides again after someone else has already performed, interpreted and billed for the tests -- a very unlikely circumstance when it comes to a KOH or wet mount.