Ob-Gyn Coding Alert

When a patient makes an appointment with her ob/gyn, the assumption is that she is seeing her doctor for problem-oriented or preventive care related to gynecology or obstetrics. But what happens when the patient reports with complaints of anxiety, depression or some other psychological complaint? Time-based coding and the appropriate diagnosis codes are critical to reimbursement for these visits.
 
Patients who are comfortable with their ob/gyn practitioner are likely to think of him or her as their primary care provider, and therefore report to the ob/gyn with a variety of medical and nonmedical problems. These can include everything from a simple head cold to severe depression or anxiety. Often, the patient will not tell the office the reason for her visit until she is behind closed doors with the physician, particularly if the problem is psychological. In some cases the patient's insurance may not cover psychotherapy, and she must look to another medical provider for assistance. 

 
If a patient reports with complaints of anxiety or depression and the ob/gyn opts to treat her rather than refer her to a psychologist or psychiatrist, the majority of the visit is likely to be spent in counseling. Wanda D. Brown, CPC, president of ProActive Coding Service and an independent coding consultant in Jacksonville, Fla., says that when you determine an E/M level for a visit that is primarily counseling, history and medical decision-making are key factors.
 
"Assuming I'm an established patient of my ob/gyn's," Brown says, "chances are if I show up with a complaint that I'm depressed and can't stop crying, the doctor is probably not going to do a pelvic examination. The odds are that he or she will do a minimal examination that includes checking heart rate, cardiovascular function, etc." In Brown's example, the level of examination might not be high enough to bill a level-three or -four established-patient visit.
 
But to ascertain the severity or sources of the psychological problem, the physician will likely take a detailed history, with history of present illness (HPI); review of pertinent systems; and past, family and social history (PFSH). The HPI will help the physician determine whether the depression is chronic or circumstantial. Medical decision-making could involve a prescription for antidepressants, scheduling a follow-up visit or referring the patient to a specialist. "I'll generally write pre-scriptions if I feel they're needed," says Harry Stuber, MD, an ob/gyn who practices in Cookeville, Tenn., "or I refer the patient to a mental-health worker if I feel the problem is severe, prolonged or beyond my capabilities as an ob/gyn."   

 
Assuming that selection of the E/M level will rest on history and medical decision-making, time will make the difference between a low-level and higher-level visit. "When face-to-face counseling time accounts for more than 50 percent of the visit," Brown says, "this becomes the determining factor in the E/M level." When that happens, she says, the degree of history and medical decision-making is not as important, and physicians should pick the E/M code based on how much time was spent discussing the patient's problem.
 
For example, if the physician spent 25 minutes or more counseling an established patient, he or she would code the visit as 99214 (office or other outpatient visit for the evaluation and management of an established patient ...). "The documentation of the visit will have to show how long the entire visit lasted," Brown says. If, during a 30-minute visit, 20 minutes were spent talking to the patient, the note will have to indicate this and state specifically what was discussed. "Time is normally the last factor considered in the visit," Brown says. 
 
Since the physician typically won't know ahead of time how long the visit will take, he or she will still need to document the history and medical decision-making and whether an exam was necessary. "So you've already reached a certain E/M level with these two factors," Brown says. When a 15-minute visit turns into a 35-minute visit, the physician must document the time in order to be fairly compensated for time spent with the patient.
 
Stuber says, "My notation will read something like, 'Patient in for an encounter dominated by counseling and coordination of care, which lasted 15 minutes. We discussed ...' Then I'll code the visit based on the time grid, figuring that 15 minutes face time with an established patient is a 99213."

 
When ob/gyns treat their patients for anxiety or depression, diagnostic coding can cause reimbursement problems. Some carriers will not pay for a nonmental-health provider to treat patients for psychological disorders. Brown says that in her experience with both primary care physicians (PCPs) and ob/gyns, coding for anxiety or mental-health diagnoses are frequently non-payable. "Mental-health codes are often carved out by private insurers," Brown says. "The practice will get an explanation of benefits (EOB) that says they (the carrier) will not pay because the diagnostic code submitted was for anxiety or depression (300.4, neurotic depression)."
 
However, she has found that short-term situational depression (309.0-309.3, adjustment reaction) is usually reimbursable when applied by nonmental-health practitioners. As always, physicians or coders should choose the diagnostic code based on what best matches the problem, rather than what they will be paid for. But if the patient is experiencing recent, short-term depression triggered by events in her life, a code from the adjustment-reaction coding group is the most appropriate.
 
Physicians and coders should also look at the patient's overall health to determine the cause of the anxiety. For instance, if a patient has begun to show menopausal symptoms, her depression could be linked to that. In such a case, Brown says, coders should report the menopausal status as the primary diagnosis, 627.8 (other specified menopausal and postmenopausal disorders), and code for the depression as the secondary code, e.g., 296.2 (major depressive disorder, single episode). The menopause code tells the carrier the root cause of the secondary code. The same is true for premenstrual syndrome. A primary diagnosis of 625.4 (premenstrual tension syndromes) will support the secondary-diagnosis code of depression or anxiety and ultimately make more sense to the carrier as an ob/gyn-related problem.
 
"It is still essential for providers to bill for what they do and what they discover," Brown says. But if there are underlying factors like menopause, PMS, grief over a death or some other factor, the payer should not hold up these claims.