Ob-Gyn Coding Alert

When a patient shows up for a well-woman visit, she often reports with additional problems. A physician can easily use extra time and expertise with these complaints. Reimbursement for the extra work is based on the severity of the complaint, the amount of work performed during the visit and, most important, the documentation that supports billing for an extra service.
 
A reader question in the July 2001 issue of Ob-Gyn Coding Alert advised against billing a separate E/M service when a patient reported for her annual well woman and also complained of pelvic pain. Stephanie Denney, office manager for Laurel Highlands Ob-Gyn, PC, a four-physician practice with three offices in central Pennsylvania, wrote that she was concerned with this recommendation. "ACOG gives examples of how to code both preventive and problem-oriented care in the same visit," Denney says, "and I disagree with your recommendation against billing for the E/M." In response, we sought to illuminate the differences between when it is appropriate to bill for an additional E/M service and when it is not.
Coders Need To Ask the Right Questions  
When an unexpected service is performed on a patient during a routine E/M visit (e.g., an aspiration of a breast mass), coding for the extra work is fairly straightforward: The physician codes for the procedure performed, and the E/M visit is appended with modifier -25 for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. But coding becomes more confusing when the patient comes in for a well-woman exam and also reports a complaint that does not involve a procedure.
 
CPT addresses the issue of combined preventive and problem-oriented care at the beginning of its section titled "Preventive Medicine Services." CPT's rules state that "An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive E/M service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported." Therefore, knowing when to bill for both a well-woman service and an E/M visit and when the additional service is not significant enough to carve out requires a case-by-case evaluation by the physician and the coder. For documentation, more emphasis is placed on history and medical decision-making because the physician can't be credited twice with the same exam.
 
Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert, says there are several questions the physician and coder should ask when determining whether an additional E/M visit can be carved out from the well-woman exam:
 
Is a separate complaint documented with a diagnostic code?
 
Was the process of identifying and treating [...]