Reader Questions:
E/M May Be the Answer to BCP for Acne
Published on Tue Feb 07, 2006
Question: When a patient receives birth control pills (BCP) because her dermatologist wanted her on them due to an acne medication, how should I code that? One person said I shouldn't even code the BCP, but if this was the only problem the patient presented to the ob-gyn for, does that mean I should still not code for it to keep with specificity?
Virginia Subscriber
Answer: If the reason the ob-gyn prescribes the BCPs is acne, that is what you code as a diagnosis (706.1, Other acne; acne: NOS, conglobata, cystic, pustular, vulgaris, blackhead, comedo). The patient is not there for contraception to prevent pregnancy.
If you want to list birth control as the secondary diagnosis (V25.01, Prescription of oral contraceptives), that is your choice. Because this visit is to deal with a problem the patient has, rather than for a preventive service, you will report an E/M service for this encounter using a problem E/M code (99201-99215). Check your ob-gyn's documentation for history, exam, and medical decision-making to choose the correct level of E/M code.
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