Ob-Gyn Coding Alert

Question: Is there a CPT code we can report (other than the Medicare code) for pelvic examination on a patient who had a total hysterectomy? I've faxed Blue Cross Blue Shield this question several times and have received no response.

Mississippi Subscriber


Answer: You should use the same preventive code you would use when the the patient still has her uterus, or use the code Blue Cross Blue Shield has designated as the code you should use for a preventive exam-ination. In this case, your diagnosis code will be V72.31 (Routine gynecological examination) because the physician will still be doing a pelvic exam. You can use this code whether or not the ob-gyn collected a Pap smear specimen at the time of the visit.
 
If the ob-gyn collected a vaginal Pap smear at the time of the exam and he did not remove the patient's uterus due to cancer, you can use a secondary diagnosis of V76.47 (Special screening for malignant neoplasms, vagina).
 
The preventive codes do not stipulate required history and exam elements, as would be necessary for a problem E/M service, so you should be using the preventive guidelines established by the American College of Obstetricians and Gynecologists.
 
Your documentation should include an exam that is age- and gender-specific for the patient's needs, not the Medicare examination. You should also include a statement that the uterus and ovaries have been surgically removed.