Wiki How to bill for contraceptive management visit

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cbeste

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A patient came in to establish care with one of our providers and for contraceptive management. The provider documented the decision to obtain old records from the patient's previous provider and the rest of the visit involved contraceptive counseling. Can a problem-based visit code be used even though there is not an illness or injury? Can contraceptive management be considered a chief complaint and can documentation on the history of contraceptive use be used towards the HPI? The visit cannot be billed as a preventive care visit because the only element of a physical exam was taking the patient's vital signs. I would really appreciate some advice on how to code this scenario.
 
If the physician spent the majority of the visit counseling the patient for contraceptives, the visit can be billed based on time. However, the physician must have documented the content of the discussion as well as a statement saying the total time spent with the patient and that more than 50% of the visit was spent in counseling and coordination of care. If this was not done, than you would have code it based on the E/M guidelines. The physicians need to be educated on the proper documentation to bill on time in these situations. The diagnosis code would be one from V25.0x depending on what type of contraceptive.
 
Thank you for the response. The problem is that the provider did not document the time spent counseling or the total time of the visit. Is is possible to still bill a problem-based visit code using contraceptive management as the chief complaint and elements of the history of contraceptive use as the HPI?
 
Contraceptive billing

I bill OBGyn and constantly have pts that come in for b/c options discussion...I have billed from level 3 to level 4 (depending if time is mentioned) w/ V25.40. Never had an issue. Hope this helps.
 
cbeste said:
Thank you for the response. The problem is that the provider did not document the time spent counseling or the total time of the visit. Is is possible to still bill a problem-based visit code using contraceptive management as the chief complaint and elements of the history of contraceptive use as the HPI?
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I would say you could bill a problem focused visit if you have a problem focused history (history of contraceptive use would fall under past history, so you would need at least one other thing documented for an HPI) and a problem focused exam with the vitals taken. Contraceptive management would be the CC. If the doctor has documented at least this information you could bill 99201 for a new patient.

Hope this helps!
 
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