Ob-Gyn Coding Alert

Question: During an audit review, we had a physician mention other practices were getting a higher E/M level (99215) with POP-Q evaluations. Does any gynecology clinic use a special format on appointments when their doctors see a patient for whom they do the measurements?

Iowa Subscriber

Answer: No. Ob-gyns perform a pelvic organ prolapse quantification (POP-Q) exam to quantify, describe, and stage pelvic support, and therefore it’s just a more specific gynecology exam. It falls under the same rules that apply to all. You’ll base it on the number of elements examined (1997 guidelines) or an extended exam of one organ system with additional systems/body areas (1995 guidelines).

Most of the time, a 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) won’t hold up for a POP-Q exam because the medical decision making is not high enough complexity. Note: You might reach a higher complexity if the patient had many more co-morbidities that puts her at risk for management options.