Ob-Gyn Coding Alert

Reader Questions:

Confidently Report Counseling Codes in Conjunction with E/M

Question: Can an ob-gyn bill for alcohol abuse and intervention in addition to an E/M visit?

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Answer: Yes. Counseling codes, according to the CPT® Evaluation and Management/Preventative Medicine Services guidelines, “are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed.”

What this essentially means is that it’s likely the patient did not come into the ob-gyn’s office to discuss alcohol abuse, so a separate discussion with its own treatment trajectory will take place, warranting a separate code. Consider the following:

A new patient presents to the ob-gyn with painful and persistent heartburn, difficulty swallowing, and vomiting. The patient has clammy skin and, when asked, reports feeling tired constantly. The patient smells like alcohol and admits they’d been drinking that day. The physician decides to conduct the Alcohol Use Disorders Identification Test (AUDIT).

The test results suggest the patient is moderately to severely alcohol-dependent and the provider spends 12 additional minutes counseling the patient and providing information on support groups, then recommends a follow-up to check for cirrhosis.

The entire alcohol counseling portion of the encounter took 21 minutes. The physician finished up the original E/M service and prescribed an over-the-counter antacid for the heartburn.

How to code it: The ob-gyn performed both an E/M service and alcohol counseling, so you would report the following codes:

  • 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter) for the original E/M visit
  • 99408 (Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes) for the counseling
  • 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) appended to 99202 to show that the E/M and counseling were separate services
  • R12 (Heartburn)
  • R13.10 (Difficulty in swallowing NOS)
  • R11.10 (Vomiting, unspecified)
  • R23.1 (Pallor)
  • R53.83 (Other fatigue)
  • Z71.4 (Alcohol abuse counseling and surveillance)
  • F10.20 (Alcohol dependence, uncomplicated) to satisfy the Use additional code note for Z71.4.