Ob-Gyn Coding Alert

Question: Patient came for her well woman checkup. She also had amenorrhea and intrauterine device (IUD) removal. I billed this encounter with 99395, 88142, 99213-25, and 58301. Is this correct?

Georgia Subscriber

Answer: No. You should not be billing 88142 (Cytopathology, cervical or vaginal [any reporting system], collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision) because your ob-gyn is not doing the Pap interpretation. The Pap collection is part of the preventive service, which means you should not bill it separately.

Only bill the problem E/M service (like 99213, Office or other outpatient visit …) if you have a significant separate E/M note that addresses the amenorrhea and does not double count the items that would be part of the preventive service.

Technically, you would also need a 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) on the 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years) since a procedure was performed at the time of both the problem and preventive services.