Ob-Gyn Coding Alert

Question: Patient had a suction dilation and curettage (D&C) after an incomplete miscarriage on 4/04/19. She came to the office on 4/22/19 for a post op visit and to discuss her desire for permanent sterilization as the D&C was very emotional. The provider performed an exam, history and counseling regarding the bilateral tubal ligation. The patient also has a family history of ovarian cancer. The provider wants to bill a 99214. Is this billable if the documentation supports? Or is this included in the global?

California Subscriber

Answer: You should include part of this visit in the global, so you would have to be able to separate out the part that only dealt with counseling for the tubal. You have no need to repeat the history or the exam for a tubal discussion, and the family history of ovarian cancer would also have to have been addressed as part of counseling to count it.

Your ob-gyn’s documentation will probably not come up to a 99214-24 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; a detailed examination; medical decision making of moderate complexity; Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)if based just on the countable elements that applied to the counseling. However, if your provider would consider an addendum to the record which would indicate the total face-to-face time for the encounter and what part of that time was only for counseling the patient with regard to contraceptive options, you might be able to report at least a 99213-24 service linked to a Z code for contraceptive counseling.