Ob-Gyn Coding Alert

Question: Knowing how important it is to keep patients informed about a planned surgery, what is a good way to code extensive preoperative discussions with the patient so that we receive fair reimbursement? Currently we hold such discussions as part of the visit at which we do a new-patient history and physical. Many of our patients have extensive questions about their proposed operations. Is there a more efficient way for us to code these discussions and be adequately reimbursed?

Anonymous NH Subscriber

Answer: If you see a patient with a problem that may necessitate surgery, and she is a new patient (99201-99205) to you, you will of course perform a history and exam, and review old records and tests. You can discuss details of surgery with the patient either at that visit or at a later one when she decides to allow the surgery to be performed. You may also be able to bill an E/M service with time as the controlling factor, even on those visits where you also do a minor exam.

However, the E/M service must be dominated by counseling (that is 50 percent or more of the physician face-to-face time) in order for time to be a deciding factor. There must be documentation for the time and the reasons behind the time.