Ob-Gyn Coding Alert

Improper coding of consultations and referrals can lead to two major problems:

1. Practices that miss opportunities to code legitimately for consultations lose precious reimbursement dollars by not coding to a high enough level, and

2. Practices that improperly code for consultations when a lesser code is correct run the risk of both an audit and fraud allegations.

Curtis Udell, CPAR, CPC, president of Emphysys, a medical coding consulting company in Cumming, Ga., says that consultation coding is a critical issue for ob/gyns in particular because they treat or refer patients for a variety of specialized problems, like infertility, high-risk pregnancy or ill-defined conditions.

CPT 2001 and HCFA each devote much space to defining consultations. HCFAs rules are contained in the Medicare Carriers Manual (MCM) Part 3, Chapter XV Fee Schedule for Physicians Service, section 15506, Consultations.

CPT defines a consultation as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

CPT also presents four categories of consultations: 99241-99245 for outpatient consultations, 99251-99255 for inpatient consultations, 99261-99263 for followup inpatient consultations and 99271-99275 for confirmatory consultations.

Clinical Scenarios

The following clinical scenarios are specific to ob/gyn and identify what type (if any) of consultation should be coded:

Scenario #1: A 54-year-old postmenopausal woman reports to her primary care physician (PCP) with complaints of vaginal bleeding. The PCP refers her to her ob/gyn. The ob/gyn sees this established patient, adjusts her estrogen prescription and plans an endometrial biopsy the following week.

The correct code: The ob/gyn should code the visit 9921x for an established patient office visit.

The reason: The patient is being referred to her ob/gyn for the treatment of a specific problem. The ob/gyn is not being asked for an opinion; rather it is assumed she will manage the care of the womans problem.

Scenario #2: A 23-year-old indigent woman reports to the emergency department (ED) with severe cramping and bleeding. The ED physician examines her, orders an ultrasound and contacts the ob/gyn on call. The ob/gyn views the ultrasound film, which shows an ectopic pregnancy. He admits the patient, performs a D&C (dilation and curettage) and assumes followup care until her release.

The correct code: The initial visit in the ED by the ob/gyn on call is coded 9925x-57 for initial consultation of a new or established patient and for decision for surgery. Use modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) instead of modifier -57 if the payer requires it.

The reason: The E/M [...]