Ob-Gyn Coding Alert

Here’s how to make diagnosis codes support your claim.

You could be missing out if you don’t report preventive medicine counseling codes 99401-99404 on the same day as a problem-based E/M visit when your ob-gyn counsels the patient on an unrelated issue.

Crux of the problem: Sometimes a patient comes in for preventive care/counseling without a specific problem or complaint, and coders are hesitant to code these visits correctly because they are worried about the insurance company not paying for the service. But what you should remember is that we have to code correctly to the service, not code to be paid. 

Learn how to determine which code to report and what documentation you need using these two scenarios.

Decide How to Code These Situations

Situation 1: The ob-gyn spends 15 minutes discussing and prescribing birth-control pills during a preventive medicine counseling session with an adolescent patient. How should you report this?

Situation 2: An established patient presents to your ob-gyn and wants counseling as to whether she should have the HPV vaccine. Once she learns about its benefits, she wants to have the vaccine on the same day.

Answer 1: Conquer This Birth-Control Example

You should report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) and link it to V25.01 (Encounter for contraceptive management; General counseling on prescription of oral contraceptives).

When the physician prescribes alternatives such as the contraceptive patch during a preventive medicine counseling session, link V25.02 (General counseling on initiation of other contraceptive measures) to the appropriate code for preventive medicine, individual counseling (99401-99404). However, code V25.02 excludes intrauterine devices (IUDs).

Remember: 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.

Note: 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, Office or other outpatient visit for the evaluation and management of an established patient ...) with a birth-control diagnosis (V25.4x). Reason: The physician is now monitoring the side effects of the drug, coding experts say. Most of these visits will involve counseling. To make sure your documentation has what it takes, you should go through this checklist:

1. Does the documentation reveal the total face-to-face time in the outpatient setting?

2. Does the documentation describe the content of the counseling or coordination of care?

3. 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). Be aware that some insurance carriers ask for specific documentation that shows the time the counseling began and ended.

Answer 2: Help Yourself by Tackling HPV Problem

For this situation, you should report:

• one of the 99401-99404 codes
• 90649 (Human papilloma virus [HPV] vaccine, types 6, 11, 16, 18 [quadrivalent], 3-dose schedule, for intramuscular use) or 90650 (Human Papilloma virus (HPV) vaccine, types 16, 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.

Keep in mind: You should link 99401-99404 with V65.45 (Counseling on other sexually transmitted diseases). Also, you should link 90649 or 90650 and 90471 with a diagnosis of either V04.89 (Need for prophylactic vaccination and inoculation against certain viral diseases; other viral diseases) or V05.8 (Need for other prophylactic vaccination and inoculation against single diseases; other specified disease), depending on payer preferences.

Don’t forget: 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.