Ob-Gyn Coding Alert

Question: During an audit review, we had a physician mention other practices were getting a higher E/M level (99215) with pelvic organ prolapse quantification (POP-Q) evaluations. Does any gynecology clinic use a special format on appointments when its doctors see a patient for whom they do the measurements?

Wisconsin Subscriber

Answer: No. Ob-gyns perform a POP-Q exam to quantify, describe, and stage pelvic support; therefore, it’s just a more specific gynecology exam. It falls under the same rules that apply to all.

Most of the time, a 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) won’t hold up for a POP-Q exam because the medical decision making is not high enough complexity. Note: You might reach a higher complexity if the patient had many more co-morbidities that put her at risk for management options.