Ob-Gyn Coding Alert

Question: I work for a large multi-specialty practice. I know that I can bill a preventive and E/M on the same day when a physician works up new or existing problems and documents it. Do the same documentation guidelines apply to ob-gyns?

South Carolina Subscriber

Answer: The same rules apply to any specialty billing both a preventive (99381-99397, Preventive medicine service) and problem E/M (99201-99215, Office or other outpatient visit) on the same day. For ob-gyn patients, there may be some extras you don't recognize right off the bat.

For instance, you have to include discussions about birth control or hormone replacement therapy in the absence of complaints that require evaluation and management. Also, you should include minor problems like prescription renewal for a stable condition. You-ll also include the mention of any problem as part of history that the ob-gyn does not actively manage at this visit.