Ob-Gyn Coding Alert

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.

Question: Can sonograms be billed in addition to  office visits or are they always bundled?

Maine Subscriber

Answer: You can get paid for the E/M and the procedure on the same day, but make sure to attach a diagnosis code to the E/M code that refers to the symptoms that brought the patient to the office, and a diagnosis code for the sonogram that reveals the findings.
 
For example, if the patient scheduled the visit with a complaint of pelvic pain, you would link the E/M code (e.g., 9921x, office or other outpatient visit for the evaluation and management of an established patient) with a diagnosis of 625.9 (unspecified symptom associated with female genital organs). If the sonogram reveals a cyst, it would then be coded, depending on approach, as (e.g., 76830, ultrasound, transvaginal) with the cyst as the diagnosis (e.g., 620.2, other and unspecified ovarian cyst).
 
The E/M may also require modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) for some payers when billed with any other service.