Ob-Gyn Coding Alert

Question: A patient presents herself to our office for a pelvic exam and Pap smear only. (She had a preventive exam with her non-ob/gyn primary care physician, but that didnt include the pelvic exam.) We are in a dilemma over the correct E/M code to use, since we did not do a complete physical exam. Are the preventive medicine codes appropriate? Also, the patient has no symptoms, so the diagnosis code would have to be V72.3 (Pap smear and pelvic exam) or V76.2 (cervix screening), but I have been told that these diagnosis codes do not go along with E/M visit codes.

Leslie Oliveira, Financial Coordinator
Womens Health Care

Answer: According to the AMAs CPT Companion, a preventive exam that is less than comprehensive should be coded using the appropriate level of E/M service. A pelvic exam, assuming you also performed a gyn-related history, will, in the opinion of the coding authorities at the American College of Obstetricians and Gynecologists (ACOG) allow you to bill at least a level 3 E/M established patient service (99213) or level 2 new patient service (99202). The only correct diagnosis code would be V72.3. There is no coding rule that says you cannot use a V code with a problem-oriented E/M service, but if you have problems with the payer, it may be because the patient does not have coverage for an annual exam.