I am looking at some claims for an OB/GYN practice. One of the situations is this.
33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".
She counseled the patient regarding the findings, possible diagnoses, and possible treatment options. She documented the discussion and time spent very clearly.
The patient decided to have surgery the following Monday. The patient returned to the clinic a third time (the same date) with her husband. The doctor explained the results of the testing's and exam to the patient and her husband answered all of their questions and documented the start and stop times of the visit. I am posting what she coded and then what I think it should be coded as and I would like your opinion.
Provider Coding
1st visit same date:
CPT DX
99395 V72.31
99213 V72.31; 620.2; 625.3; 250.00
76830 620.2
81002 V72.31
2nd visit same date:
99213 789.33; 625.3; 250.00; 218.9
76830 789.33
3rd visit same date:
99215 625.3; 250.00; 218.9 752.11; V26.49; V72.83
She did not use any modifiers.
I believe it should be coded as follows. My only concern is that the rules say not to bill prolonged care with a preventive medicine visit. I think in this case it is OK because there is a separate E&M code. The total time spent in counseling is 90 minutes. Please let me know what your opinion is.
Visit 1 (Claim 1)
CPT DX
99395 V72.31; V76.47; V73.81 (she did provide these services) 625.3
81002 V72.31
2nd & 3rd visit same date (because all of the appropriate diagnosis codes will not fit on one claim)
99215-25 789.33, 625.3, V72.83
99354 789.33, 625.3
76830 789.33
76830-76 789.33, 625.3, V72.83
I want to use this case in my advanced E&M coding course and want more than my opinion on the accuracy of the coding. Please let me know what you think.
33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".
She counseled the patient regarding the findings, possible diagnoses, and possible treatment options. She documented the discussion and time spent very clearly.
The patient decided to have surgery the following Monday. The patient returned to the clinic a third time (the same date) with her husband. The doctor explained the results of the testing's and exam to the patient and her husband answered all of their questions and documented the start and stop times of the visit. I am posting what she coded and then what I think it should be coded as and I would like your opinion.
Provider Coding
1st visit same date:
CPT DX
99395 V72.31
99213 V72.31; 620.2; 625.3; 250.00
76830 620.2
81002 V72.31
2nd visit same date:
99213 789.33; 625.3; 250.00; 218.9
76830 789.33
3rd visit same date:
99215 625.3; 250.00; 218.9 752.11; V26.49; V72.83
She did not use any modifiers.
I believe it should be coded as follows. My only concern is that the rules say not to bill prolonged care with a preventive medicine visit. I think in this case it is OK because there is a separate E&M code. The total time spent in counseling is 90 minutes. Please let me know what your opinion is.
Visit 1 (Claim 1)
CPT DX
99395 V72.31; V76.47; V73.81 (she did provide these services) 625.3
81002 V72.31
2nd & 3rd visit same date (because all of the appropriate diagnosis codes will not fit on one claim)
99215-25 789.33, 625.3, V72.83
99354 789.33, 625.3
76830 789.33
76830-76 789.33, 625.3, V72.83
I want to use this case in my advanced E&M coding course and want more than my opinion on the accuracy of the coding. Please let me know what you think.