Ob-Gyn Coding Alert

Here’s what your physician’s documentation needs to include.

Since January 1, you can use new add-on code +99459 (Pelvic examination (List separately in addition to code for primary procedure)), but many coders are still confused as to how they can report this. This FAQ can help.

Question 1: Why Did CMS Implement This Code?

According to the American College of Obstetricians and Gynecologists (ACOG), Centers for Medicare & Medicaid Services (CMS) created this to “assist with the cost of pelvic examination packs, such as speculums, and in-room chaperones for patients receiving female pelvic examinations during an outpatient evaluation & management visit.”

This incurs a big expense. In 2015, for instance, 52 million pelvic exams were performed in the United States, meaning that having this practice expense only code can offset the costs ob-gyns and other physicians incur. Keep in mind that the relative value assigned to this code was based on the assumption that both an in-room chaperone and pelvic exam pack are being utilized.

Question 2: What Codes Can I Report +99459 With?

So long as your physician documents the pelvic exams correctly, you can report +99459 with one of the following evaluation and management (E/M) codes:

• Office or other outpatient visit for the evaluation and management of a new patient codes (99202-99205)
• Office or other outpatient visit for the evaluation and management of an established patient codes (99212-99215)
• Consultation codes (99242-99245)
• Preventive visit code (99383-99387, 99393-99397)

Note: If your ob-gyn is seeing a Medicare patient for a preventive visit, you will instead use one of the following HCPCS codes:

• G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
• G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit)
• G0439 (… subsequent visit)
• G0468 (Federally qualified health center (FQHC) visit, IPPE or AWV; a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV)

We do not yet have guidance about whether you can report +99459 with these HCPCS codes. However, when a Medicare-eligible patient receives a screening pelvic exam, the codes G0101 for the pelvic exam and Q0091 for the collection work can be reported along with one of these preventive services. Both codes include practice expense relative values specially addressing the costs of performing the exam, so it would seem unlikely that +99459 will be allowed in addition.

Question 3: What Codes Should I Not Report +99459 With?

You cannot report +99459 with several codes, which include:

• A postoperative visit (99024, Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure), as it is included in the global surgical codes
• Medicare codes G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory)

Question 4: How Often Can I Report This Code?

You will only report this code once per patient per day when this service occurs alongside one of the codes listed above.

Question 5: What Documentation Does the Ob-Gyn Need to Provide?

According to ACOG, “documentation in the medical record must support the need for the pelvic examination and confirm the use of a chaperone.”

For instance, says Melanie Witt, RN, MA, an independent coding consultant in Guadalupita, New Mexico, “a ‘chaperone present: yes/no’ tick box could be added to the EHR [electronic health record] template for a pelvic exam, or a statement could be added such as ‘chaperone present during pelvic exam.’” There is currently no published rules that require the name of the chaperone to be part of the record, Witt adds.

Also, “ACOG guidance indicates that pelvic examination should be performed when indicated by medical history or symptoms or as a result of shared decision making between the patient and their obstetrician-gynecologist or other gynecologic care professional.”

Remember: A pelvic exam may or may not be performed at the annual preventive visit, and one would not be required before providing contraception. However, a pelvic exam would most likely be performed if the provider is screening for sexually transmitted infections, and a pelvic exam would always be performed prior to some gynecologic procedures, such as an intrauterine device (IUD) insertion. “This does not mean that the add-on code can be reported when an exam is performed under these circumstances,” Witt says. This is because a pelvic pack and pre-procedure evaluation time has already been accounted for in the practice expense relative value assigned to the IUD insertion code (58300).