Ob-Gyn Coding Alert

Question: An established Medicare patient presents at the clinic for a well woman examination, which includes a breast exam and a Pap smear. The patient is eligible for a Pap smear her last one was 3 1/2 years ago. During the exam a polyp is located on her cervix and the doctor makes the decision to perform a biopsy of the polyp. When coding this visit is it acceptable to bill as follows:

99386-QB the diagnosis is V76.2
G0101-QB the diagnosis is V76.2
99203-25-57 the diagnostic codes are 622.7 and 626.0
57454-QB the diagnosis is 622.7.

CPT guidelines suggest that an evaluation and management (E/M) visit can be billed along with the preventive medicine exam code, but Ive never understood it this way from previous instruction. Are we coding correctly?

Rhonda Barber
Perryville Family Care Clinic, Perryville, Mo.

Answer: CPT allows coding for both a problem and preventive E/M service at the same encounter and also states that you can bill for a problem E/M service and a procedure on the same day. However, the documentation must clearly show that the problem E/M service was separate and significant from the preventive service or the procedure. For example, in order to bill 99203 (office or other outpatient visit for the evaluation and management of a new patient ...), the documentation must show a detailed history, detailed exam and low-complexity medical decision-making concerning only the polyp, but you cannot count history and examination elements already done as part of the preventive exam.

In this case, you are suggesting coding for two parts of a preventive service a problem E/M service and a procedure at the same encounter but this is overcoding. In the absence of knowing what was documented in the medical record, it would seem more likely that the patient would not have complained of symptoms that led to the discovery of the polyp, but rather this was an incidental finding at the time of the preventive visit. If this is so, a problem E/M service would not be billed in addition to the preventive services. Your documentation must also show a separate and significant E/M service when a procedure is billed at the same encounter, and if the major service following the discovery was its removal, it is unlikely the documentation is in place.

If you believe that a separate and significant E/M service was documented in the record (separate from both the preventive service and the procedure) you can certainly bill for it, but the only modifier you would apply is modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier -57 (decision for surgery) is for the decision to perform major surgery the day of or day before the actual surgery, not for minor office procedures.

You can, however, bill additionally for the removal of the polyp at the time of a preventive visit. In this case, you indicate that the polyp was removed during a colposcopic examination. You also note that the patient was Medicare eligible and that you could bill for her Pap smear at the visit in question. You indicate this by listing the code G0101. But this code is not for a Pap smear; its for a screening pelvic/breast exam, which also has the same timing restrictions as a Pap smear. If the patient is eligible for the screening pelvic/breast exam and Pap smear interpretation, you can bill Medicare using G0101 and Q0091 (for the collection of the specimen). You would then bill the patient for the remainder of the comprehensive preventive service that Medicare is not responsible for. Before treatment, the patient should sign an advanced beneficiary notice (ABN) acknowledging that she is responsible for the preventative service portion of the encounter.

Therefore, your coding would look like this:

99386-QB initial preventative medicine evaluation and management of an individual including a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, new patient; 40-64 years; -physician providing service in a rural HPSA

If the patient were 65 or older you would use 99387 ( ... 65 years and over). You need the -QB modifier only if Medicare covers this service (which is not the case most of the time). Otherwise, you would be billing the patient for this non-Medicare-covered portion of the preventive service. The diagnosis for this code can be either V70.0 (general health examination) because you are already billing V76.2 (routine cervical Papanicolaou smear) for the Medicare-covered screening exam or V72.3 (gynecological examination).

G0101-QB cervical or vaginal cancer screening; pelvic and clinical breast examination

Bill this code to Medicare with a diagnosis of V76.2.

Q0091-QB screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

Use this code for the Pap smear collection. It also requires the diagnosis code V76.2.

57454-QB colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage

Bill this code with a diagnosis of 622.7 (mucous polyp of cervix).

Diagnosis code 626.0 (absence of menstruation) would generally not be the code of choice for a menopausal woman. It is for someone who is not menopausal, but has not had periods for at least six months. Instead, indicate either postmenopausal symptoms (627.2) if she was complaining of any, V07.4 if she is on hormone replacement therapy and one of the reasons for the visit was monitoring her hormones, or V49.81, postmenopausal status (i.e., not on hormones).

Source for answers to You Be the Coder and Reader Questions is Melanie Witt, RN, CPC, MA, an independent coding educator.