Ob-Gyn Coding Alert

You could be missing out on $200 a week

If you rely on office visit codes (99201-99215) for your pre-op exams, you could be missing the perfect opportunity to use a higher-paying option.

When a surgeon requests your ob-gyn's opinion regarding surgical clearance for a patient, the preoperative exam or service qualifies as a consultation if the ob-gyn documents the reason for the request and issues a report of his findings to the requesting surgeon. Find Out How You Can Get an Extra $38 Many practices are losing this deserved revenue because they report an office visit, such as 99213 (Office or other outpatient visit for an established patient ... 15 minutes face-to-face) or 99214 (... 25 minutes face-to-face). But the consultation codes, for instance 99242 (Office consultation for a new or established patient ... 30 minutes face-to-face) and 99243 (... 40 minutes face-to-face), reimburse at a much higher rate.

In fact, 99213 reimburses about $38 less than its consultation equivalent 99242, based on national Medicare allowances. Because the ob-gyns do the work for a consultation, they should be paid for it. Compare 99213's and 99242's Similar Elements Despite the revenue disparity, 99213 and 99242 basically require the same elements. The difference is that 99213 requires only two of the three key components--low-complexity medical decision-making with either an expanded problem-focused history or expanded problem-focused examination, says Shari Kuehl, CCS-P, coding and reimbursement specialist at Women's Health Services in Clinton, Iowa. CPT specifies the same history and examination requirements for 99242 but allows straightforward medical decision-making.

Remember: Code 99242 requires the provider to document all three components.

Example: A general surgeon requests that an ob-gyn clear a 35-year-old ob patient in her first trimester for gallstone surgery. The general surgeon wants to make sure he can safely perform surgery without risk to the patient or her fetus. The ob-gyn performs an expanded problem-focused history, expanded problem-focused examination, and straightforward medical decision-making.

This preoperative exam would qualify for either 99213 or 99242, but you should choose 99242 for the ob-gyn's service if the criteria for billing a consultation have been met. On the other hand, if you choose the office visit code (99213, which contains 1.39 relative value units [RVUs] and reimburses $50.29) instead of the consultation code (99242, which has 2.43 RVUs and pays $87.91), you will cost your practice $37.62 per visit, based on the Medicare Physician Fee Schedule.

On average, ob-gyns perform four to five preoperative exams per week, some experts say. Consequently, if you-re using 99213 instead of 99242, you may be sacrificing nearly $200 in revenue per week. Look Closely at Chief Complaint and Findings To gain this ethical extra revenue, make sure the visit meets the three R's of a consultation. [...]