Find Out How to Capture Physicals and Birth Control Renewal
Question: My ob-gyn providers see a lot of patients for physical exams, and then they will also renew patients’ birth control as well. Is it appropriate to bill a preventive code and an evaluation and management (E/M) code with diagnosis code Z30.41? Texas Subscriber Answer: In most situations, renewing a birth control prescription during an annual preventive visit will not be sufficient to bill both a preventive and a problem-oriented E/M code with diagnosis code Z30.41 (Encounter for surveillance of contraceptive pills). In order to do so, you will have to apply 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 99202-99215 (Office or other outpatient visit for the evaluation and management …). If you were to take the documentation and cross out everything related to the preventive well woman exam, is what you have left “significant”? For straightforward renewals, most likely you would not. Perhaps you could, if the patient were having issues, such as breakthrough bleeding, heavier menses, etc. To report this, the provider must have documented and discussed this and perhaps changed the medication. In that case, you maybe have a 99202-99215 with modifier 25. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
