Pediatric Coding Alert
E/M Office Visit Codes Capture Gynecological Services
Question: How should we code the following situation? A new 16-year-old patient came in to be treated for irregular menses. The documentation for the visit also indicates that she received a physical, pelvic exam and contraceptive counseling. Washington Reader Answer: You should code this situation according to the total face-to-face physician work provided. The new and established patient office visit codes (99201-99215) include a time component, but the adolescent preventive medicine exam codes (99384 and 99394) are not based on time the pediatrician spent with the patient.
There is no separate pelvic exam code, so 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; adolescent [age 12 through 17 years]) would have to absorb the time spent doing the pelvic exam and all the counseling involved.
If the exam is a preventive medicine visit, you could append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to an established patient E/M code (99211-99215), depending on the work provided for the separately identified problem. Link the appropriate E/M code to the diagnosis code for irregular menses (626.4)
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