Ob-Gyn Coding Alert

Question: A new patient came in for her annual well woman exam and during this visit the ob-gyn gave her preconception counseling. He states, "I spent an additional 15 minutes counseling over and above the usual time spend or an annual exam." The preventive codes, however, are based on age, not time. Am I correct in assuming we cannot bill an additional E/M visit code based on this statement?

South Dakota Subscriber

Answer: You are correct. You should include the 15 minutes of preconception counseling in the new patient preventive service code (99385, Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender- appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; 18-39 years or 99386, ... 40-64 years).

If the ob-gyn documented the patient sought counseling for a problem she had with her last pregnancy, however, you can carve out a problem E/M service (99201- 99215, Office or other outpatient visit ...) and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). But to do this he could not use his statement regarding time to pick the level of service. Instead, he would document something like "The patient also presented for a discussion of preconception problems regarding... I spent a total of 15 minutes counseling this patient regarding these issues/problems."