Ob-Gyn Coding Alert

When a patient makes an appointment with her ob/gyn, the assumption is that she is seeing her doctor for problem-oriented or preventive care related to gynecology or obstetrics. But what happens when the patient reports with complaints of anxiety, depression or some other psychological complaint? Time-based coding and the appropriate diagnosis codes are critical to reimbursement for these visits.
 
Patients who are comfortable with their ob/gyn practitioner are likely to think of him or her as their primary care provider, and therefore report to the ob/gyn with a variety of medical and nonmedical problems. These can include everything from a simple head cold to severe depression or anxiety. Often, the patient will not tell the office the reason for her visit until she is behind closed doors with the physician, particularly if the problem is psychological. In some cases the patient's insurance may not cover psychotherapy, and she must look to another medical provider for assistance. 
Exam May Be Minimal  
If a patient reports with complaints of anxiety or depression and the ob/gyn opts to treat her rather than refer her to a psychologist or psychiatrist, the majority of the visit is likely to be spent in counseling. Wanda D. Brown, CPC, president of ProActive Coding Service and an independent coding consultant in Jacksonville, Fla., says that when you determine an E/M level for a visit that is primarily counseling, history and medical decision-making are key factors.
 
"Assuming I'm an established patient of my ob/gyn's," Brown says, "chances are if I show up with a complaint that I'm depressed and can't stop crying, the doctor is probably not going to do a pelvic examination. The odds are that he or she will do a minimal examination that includes checking heart rate, cardiovascular function, etc." In Brown's example, the level of examination might not be high enough to bill a level-three or -four established-patient visit.
 
But to ascertain the severity or sources of the psychological problem, the physician will likely take a detailed history, with history of present illness (HPI); review of pertinent systems; and past, family and social history (PFSH). The HPI will help the physician determine whether the depression is chronic or circumstantial. Medical decision-making could involve a prescription for antidepressants, scheduling a follow-up visit or referring the patient to a specialist. "I'll generally write pre-scriptions if I feel they're needed," says Harry Stuber, MD, an ob/gyn who practices in Cookeville, Tenn., "or I refer the patient to a mental-health worker if I feel the problem is severe, prolonged or beyond my capabilities as an ob/gyn."   
The Time Factor  
Assuming that selection of the E/M level will rest on history and medical decision-making, time will make the difference between [...]