Ob-Gyn Coding Alert

In the course of providing a service or performing a procedure, there are often times when circumstances require a change in what was planned. According to the CPT, a modifier provides a means for reporting that change. The 25 modifier allows for the reporting of a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.

According to Melanie Witt, RN, CPC, MA, ACOG program manager in the department of coding and nomenclature, there are three common instances when an ob/gyn practice may use the 25 modifier.

A preventive medicine exam with a sick visit. This situation is extremely common. A woman comes into the clinic for her annual gyn examination, and during the course of the exam and history, her ob/gyn discovers a problem, and then does extra work on that problem that would not usually be included in a normal preventive exam. For example, during the history portion of an annual exam, a middle-aged patient on birth control pills reveals that she has been having breakthrough bleeding. She was not worried enough to make a separate appointment and was now just mentioning it because the physician was inquiring about problems. The ob/gyn asks a few more questions and soon discovers that the patient is experiencing a problem that needs additional evaluation and management. Following CPT guidelines, the physician performs the key components of a problem-oriented E/M service. This modification to the exam is enough to allow for the use of the 25 modifier attached to the office visit code to show additional work was done, and to hopefully receive additional reimbursement.

In the above case, where the patient comes in for an exam and a problem is worked up as well, use the appropriate preventive medicine code (99384-99397) and link it to the V72.3 diagnosis code. In addition, use 99201-99215 for the office visit followed by the 25 modifier. Then link the office visit to the proper diagnosis code (in this example 626).

According to Witt, the key to correct use of the 25 modifier in this situation is to make sure that the additional work is significant enough and includes documentation of the additional history or medical decision-making. Simply noting the complaint and ordering tests during the preventive exam may not be enough for a 25 modifier, she cautions. The coding expert recommends that ob/gyn caregivers literally draw a line on the chart between their documentation of the preventive services and their notes on the disease-oriented services to show that the two are distinctly separate. The chart itself will tell if there is an additional E/M service provided and whether you can use the 25 modifier, Witt adds.

Tips: (1) Its a good idea to have your staff ask patients who are scheduling well-woman exams if they are having any specific problems when they originally call to make the appointment. And be sure to explain to patients that the management of a problem on the day of their preventive exam will be two separate services before they are surprised by the bill. (2) Many insurance carriers will not pay for both preventive and disease services done on the same day, but you should always code accurately anyway. It allows for your own cost analysis and for considering the value of various managed care contracts.

A sick visit and then a procedure is performed. Another time the 25 modifier may be used is when the patient comes in for evaluation and management of a problem, and then an unscheduled procedure is performed. For example, a woman comes in for an office visit to be checked out for vaginal pain. During the history and exam, the physician determines the patient has a Bartholins gland abscess and therefore does an I&D on the same day. The 25 modifier would be attached to the office visit to show that the visit was necessary over and above the procedure. Without the 25 modifier the insurance company will simply drop the office visit as bundled to the procedure. This is because the patient came in complaining of pain, thus you would not be paid for your initial time spent evaluating the patient. You have to show that after the history, exam and medical decision-making, the need for the procedure was determined. This is clearly different than a patient who comes to your office specifically for a biopsy.

In this scenario, code a 99201-99215 office visit followed by the 25 modifier and then link it to the diagnosis code 625.9. Then code the procedure 56420 linked to the diagnosis code 616.3 for Bartholins gland abscess.

An additional problem or procedure. In this instance, the patient presents for a scheduled procedure and, in the course of performing that procedure, an additional problem that requires evaluation and management is discovered and requires work. For example, a patient comes in for a scheduled endometrial biopsy and, during the procedure, she mentions that she discovered a lump in her breast. So, in addition to the endometrial biopsy the caregiver evaluates the breast problem. This additional work will be enough to justify the use of a 25 modifier.

In this instance, report the procedure code linked to the appropriate diagnosis code and then use 99201-99215 for the office visit with a 25 modifier and the appropriate diagnosis code. One of the keys to using the 25 modifier is to make sure you have the proper diagnosis codes to go with the services and procedures you are coding.

Tip: When a patient comes in for a procedure the 25 modifier is used only if the E/M code is additional to the procedure or procedures. If you have multiple procedures in addition to the E/M service the most expensive goes first and the rest follow with 51 modifiers to indicate multiple procedures. (Note: More on correct utilization of the -51 modifier in an upcoming issue.)