Ob-Gyn Coding Alert

Question: A new patient comes in for excessive menses for 20 days. The ob-gyn discusses the options and orders blood work. The ob-gyn makes the decision to do a biopsy at this visit. I reported 99203-57 and 58100. My payer denied the E/M as bundled, but that doesn't make sense. How would the ob-gyn know she was going to do a biopsy at this visit when the patient was new? Should I appeal?

Texas Subscriber

Answer: Yes, you should appeal the denial. Many times, you cannot make a case for an established patient visit with a procedure on the same day. But for new patients not scheduled for the procedure, your practice is entitled to reimbursement for both the E/M service and the procedure.

You should have appended modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...). Modifier 57 (Decision for surgery) tells the payer that the ob-gyn made the decision for surgery the day of or the day before a major (90 day) surgery. You'll use modifier 25 for same day minor (0 or 10 day) procedures.

Good advice: Check your payers for their individual same-day procedure policies.

-- The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.