Internal Medicine Coding Alert

Published on Tue Oct 28, 2008 PDF

Two examples show you when issue is related, separate

You could be missing out on deserved office visit pay unless you can spot documentation that proves a separate E/M service on your well-woman exam claims.

Physicians are allowed to file an E/M (99201-99215) along with well-woman examination codes, but only if the internist treats a problem "significant enough to require additional work to perform the key components of a problem-oriented E/M service," according to CPT.

Caution: You should not code an E/M if the internist does not treat a separate problem, warned Jacqueline Stack, CPC, CPC-I, CPC-E/M, CCP-P, during her recent audioconference "6 Strategies to Improve Your Preventive Billing Now" (www.audioeducator.com).

She offered this pair of contrasting well-woman scenarios to illustrate the point:

No E/M example: The internist is performing a well-woman exam for an established Medicare patient. During the visit, the patient mentions she is experiencing vaginal itching, and the internist instructs her to use an over-the-counter medicine to combat the problem. In this instance, the internist "was going to do a pelvic exam anyway because of the physical, and is really not performing a separately identifiable, additional E/M," Stack said.

E/M example: The internist is performing a well-woman exam for an established Medicare patient. During the visit, the patient mentions an aching shoulder. The physician orders an additional workup and writes a prescription. In this instance, you can report a separate E/M, explained Stack.

When you report a separate E/M along with a well-woman visit, be sure to 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 the E/M code to indicate the separate nature of the services.