Ob-Gyn Coding Alert

Two patients are seen in your ob/gyn practice. One woman is in for her annual Pap smear and pelvic exam. The other is in because she has been suffering unexplained abdominal pain. Both women will probably give a comprehensive history and receive a comprehensive evaluation. But, the codes billed for each of these procedures and the documentation required by the physician may differ greatly.

Confused? Youre not alone.

Even though the 1997 Evaluation and Management (E/M) guidelines have been put on hold indefinitely, the terms comprehensive history and comprehensive examination, as used in the CPT and both versions of E/M guidelines are causing a great deal of confusion for many ob/gyn coders. This confusion centers on the definition of these terms, the difference in documentation between the 1995 and 1997 guidelines, and whether the E/M guidelines apply to preventive medicine services, such as well-woman examinations. Here are two important points in understanding this dilemma:

1. The E/M guidelines apply to office visits, but they do not apply to preventive medicine services. Therefore, the requirements of a comprehensive history and a comprehensive examination in the guidelines are not applicable to preventive medicine services, including well-woman examinations.

2. The CPT does not define comprehensive history and comprehensive examination apart from the E/M guidelines. As a result, there are no definitions in the CPT of these terms as they apply to preventive medicine services and well-woman checks.

So, how do you code for the well-woman examination? This question can be answered by looking at a typical clinical scenario, says Melanie Witt, RN, CPC, MA, program manager for the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG). A patient makes an appointment for an annual gyn exam, which includes a review of her lifestyle and recent health history, obtaining a weight, a blood pressure check, and a thorough physical examination by a physician or nurse practitioner. A Pap smear is taken, but neither the discussion with the patient nor the physical examination reveals any signs of disease. How should this be coded?

First, says Witt, coders must remember that a well-woman examination is coded as a preventive service, not as an office visit. Second, she says, the E/M guidelines have nothing to do with preventive services. Therefore, while a well-woman check is a comprehensive history and examination, it is not regulated by the definitions of comprehensive history and comprehensive examination in the E/M guidelines.

The distinction here is that an office visit for a new or established patient must be motivated by a sign of illness or a symptom for which the patient is seeking medical attention. Commonly referred to as the history of present illness (HPI), this includes a chronological description of [...]