Ob-Gyn Coding Alert

Question: A patient comes in for an annual gyn exam, presents with no complaints, but is on oral contraceptives or estrogen replacement. Is this a screening exam or an E/M service? Since the patient is on medications that require monitoring, is the exam billable outside the screening guidelines? How do you code for this service?

Billing Supervisor from Pennsylvania

Answer: A comprehensive annual exam for a patient with no complaints should always be coded as a preventive service using the codes 99381-99397. Women who are on HRT or contraceptives are not sick and have no disease. It is the opinion of ACOG that menopause is a natural state for older women, and the fact that a physician can prevent bad things from happening in the future by giving hormones indicates it is a preventive service. The woman on birth control needs to be monitored to prevent a problem from developing, again, a natural function of a woman in childbearing years who elects to prevent pregnancy.

In addition, the preventive codes include counseling the patient about concerns and keeping healthy. Most gyns should use the preventive codes for two reasons. First, they are the most accurate to describe the service rendered (and that patient is not sick) and second, they usually pay better than an E/M problem visit when the service is covered by the patients policy. As we often point out, coverage cant be fixed with coding. If you are coding an E/M service so her insurance company will pay for an otherwise non-covered service, you are stepping over the line and could be accused of fraud.