Ob-Gyn Coding Alert

Here’s what to look for in your ob-gyn’s documentation.

Although you may know offhand what preventive medicine counseling code you should report, you could be setting yourself up for a denial if you overlook supporting documentation.

Refer to the scenarios on page 3, and see what our experts recommend in each situation.

Brush Up on This Birth Control Example

Solution 1: You should report 99401, experts say. You should link it to Z30.011 (Encounter for initial prescription of contraceptive pills).

When the physician prescribes alternatives such as the contraceptive patch during a preventive medicine counseling session, link Z30.01- (Encounter for initial prescription …) to the appropriate code for preventive medicine, individual counseling (99401-99404). You should note, however, that Z30.01- excludes intrauterine devices (IUDs).

Documentation must: Because 99401-99404 are time-based, your physician must document the amount of face-to-face time spent counseling, and the content of the counseling is crucial. Notes for the counseling visit should include references to pamphlets or other materials the physician reviewed with the patient. In this case, the physician documented 20 minutes of counseling. This is not enough time to report the next level of the service (99402), because that code requires at least 30 minutes. In other words, you always round down to the nearest code, coding experts say.

Keep in mind: If an adolescent comes in for a follow-up visit after an initial birth-control prescription, you can report a regular E/M service (99212-99215) with a birth control diagnosis (Z30.-) because the physician is now monitoring the side effects of the drug. And because most of these visits will involve counseling, you should go through this checklist to make sure your documentation has what it takes:

• Does the documentation reveal the total face-to-face time in the outpatient setting?
• Does the documentation describe the content of the counseling or coordination of care?
• Does the documentation reveal that the physician spent more than half of the time counseling or coordinating care?

If all of the answers are “Yes,” you should select the office visit E/M service level based on the total encounter time (in minutes), but be aware that some insurance carriers ask for specific documentation that shows the time the counseling began and ended.

Best bet: You’ll stand a better chance of convincing payers to reimburse for counseling if you’re able to provide particulars on the content of the discussion and reasons the physician prescribed a certain contraceptive.

Highlight These HPV Tips

Solution 2: You should report:

• One of the 99401-99404 codes
• 90649 (Human papillomavirus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use) or 90650 (Human Papilloma virus (HPV) vaccine, types 16 and 18, bivalent, 3 dose schedule, for intramuscular use) for the vaccine
• 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]) for the injection.

You should link the 99401-99404 code with Z71.89 (Other specified counseling). Also, you should link 90649 and 90471 with a diagnosis of Z23 (Encounter for immunization).

Important: If you administer the vaccine during the same visit as the counseling, you should add 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) to the 99401-99404 code.

Here’s What to Do With Problem E/M Services

Solution 3: In this case, you should report the 99401- 99404 codes in addition to the problem E/M code (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient ...). You should add modifier 25 to the problem E/M code.

Key: The urinary incontinence is not related to the on continued use of hormone replacement counseling. If the patient presents to the office for a problem visit and the doctor counsels the patient on a different issue, you can report both. To get paid for both, you would more than likely need to submit the claim with the documentation to support both codes.

Caution: You should not increase the E/M service level because of the preventive counseling. The reason is that your ob-gyn is not spending the time on the problem (N39.3- or N39.4-) but is providing preventive counseling on hormone replacement therapy. This will be particularly important for those payers that do not cover preventive care, because this means you would be hiding the fact that the ob-gyn provided a noncovered service.