Ob-Gyn Coding Alert

Question: When the ob-gyn has a procedure such as a LEEP, we dont bill for it until we have the pathology report back so that we can put the appropriate diagnosis on it. If the report shows that the patient has a malignancy, the physician will see the patient in the office within the LEEPs global period. The physician spends a significant amount of time with the patient providing extensive counseling and discussion regarding the results and surgery, chemo, or other treatment options.

The physician wants to charge for the visit, but the encounter has the same diagnosis as the related global periods procedure. Should we consider the encounter typical post-op care? Should we code this visit as an E/M or as a no-charge post op visit with 99024?

Nebraska Subscriber

Answer: A loop electrocautery excisional procedure (LEEP) does not specify what the ob-gyn did. It could be that he simply took a biopsy using the loop or that he did a conization. Depending on what the ob-gyn performed, the procedures global days will determine if you can code an E/M (such as 99212-99215, Office or other outpatient visit &) for the discussion with the patient.

The biopsy codes using this method (57460, Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix, or 57500, Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) do not have a global period. This means you can bill separately any discussion with the patient irrespective of the diagnosis you use. You do not need a modifier.

If the ob-gyn instead performed a conization of the cervix, you would report either 57461 (... with loop  electrode conization of the cervix) or 57522 (Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision). But only code 57522 has a global surgical period (90 days). This means you should include routine follow-up visits to ensure recovery from the procedure (such as 99024, Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) within that global period.

Talking to the patient about where we go from here, however, is not part of routine post-op care for the procedure. In that case, you would bill the problem E/M service for that visit with a modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to let the payer know that this visit is not part of routine care. If the patient still has the condition, you will use the same diagnosis as the one you used for the procedure.

When picking the E/M service level, you should count only that portion of the visit that is related to the discussion of further treatment options. Most of the time, you will base the level of service on counseling time and content. Be sure that both support the level of service you select.

For instance, 99214 requires a total of 25 minutes faceto- face with the patient, of which more than 50 percent was spent on counseling regarding future treatment. The ob-gyns description of the counseling content should reflect the time spent.