Revenue Cycle Insider

Question: A 48-year-old patient presents to their gynecologist for an annual preventive services visit but also mentioned several problems. The documentation says the visit lasted 25 minutes. How should I code this?

HEALTHCON Regional Attendee

Answer: If you’re billing two codes, you need to look at your documentation and split that documentation into support for each code and see whether both codes can stand on their own. It’s crucial to make sure you can get the same result.

“It’s like any other two CPT^® codes on a claim. I want to know that both things have been documented, to let me know that two things were actually performed. And it doesn’t matter what those two things are — it’s ‘was it actually done?’” said Jaci Kipreos, CPC, COC, CDEO, CPMA, CRC, CPC-I, CEMC, during a general session at AAPC’s 2025 HEALTHCON Regional.

For this encounter, you could use CPT^® code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) appended with modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service), along with +99459 (Pelvic examination (List separately in addition to code for primary procedure)).

One important note about billing for an annual preventive services visit by a gynecologist is that primary care might “want” to do that as well, she said. Still, “what constitutes a comprehensive exam is very different than something that’s particularly problem focused.”

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC