Ob-Gyn Coding Alert

When a patient shows up for a well-woman visit, she often reports with additional problems. A physician can easily use extra time and expertise with these complaints. Reimbursement for the extra work is based on the severity of the complaint, the amount of work performed during the visit and, most important, the documentation that supports billing for an extra service.
 
A reader question in the July 2001 issue of Ob-Gyn Coding Alert advised against billing a separate E/M service when a patient reported for her annual well woman and also complained of pelvic pain. Stephanie Denney, office manager for Laurel Highlands Ob-Gyn, PC, a four-physician practice with three offices in central Pennsylvania, wrote that she was concerned with this recommendation. "ACOG gives examples of how to code both preventive and problem-oriented care in the same visit," Denney says, "and I disagree with your recommendation against billing for the E/M." In response, we sought to illuminate the differences between when it is appropriate to bill for an additional E/M service and when it is not.

 
When an unexpected service is performed on a patient during a routine E/M visit (e.g., an aspiration of a breast mass), coding for the extra work is fairly straightforward: The physician codes for the procedure performed, and the E/M visit is appended with modifier -25 for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. But coding becomes more confusing when the patient comes in for a well-woman exam and also reports a complaint that does not involve a procedure.
 
CPT addresses the issue of combined preventive and problem-oriented care at the beginning of its section titled "Preventive Medicine Services." CPT's rules state that "An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive E/M service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported." Therefore, knowing when to bill for both a well-woman service and an E/M visit and when the additional service is not significant enough to carve out requires a case-by-case evaluation by the physician and the coder. For documentation, more emphasis is placed on history and medical decision-making because the physician can't be credited twice with the same exam.
 
Melanie Witt, RN, CPC, MA, an independent coding educator and ob/gyn coding expert, says there are several questions the physician and coder should ask when determining whether an additional E/M visit can be carved out from the well-woman exam:
 

Is a separate complaint documented with a diagnostic code?
 

Was the process of identifying and treating or managing the separate complaint significant?
 

Did the physician create a note about the problem in order to assign it an E/M level that is based solely on the criteria related to the problem? 

 
"First," Witt says, "there's the old adage that 'If it's not written down, it didn't happen.' And second, the physician will have to honestly ask the question, 'Was the work significant enough to seek extra payment?' "

 

Case Study 1: A 35-year-old patient reports for her annual well-woman exam. A complete examination is performed, including a pelvic exam, and a Pap smear is taken. The patient also complains that she has had moderate pelvic pain for several weeks. The physician asks her several questions about the nature, severity and length of the pain, and schedules her to come back in three days for an ultrasound (when the ultrasound technician is in the office). He also renews her prescription for oral contraceptives.
 
Coding the Case: The patient's well-woman exam would most likely code as 99395 (periodic preventive medicine reevaluation and management ... established patient; 18-39 years). The diagnostic code reported for the well-woman care is V72.3 (gynecological examination).
 
What about the complaint of pelvic pain? Although the physician did take some additional history of the problem, and medical decision-making was involved, it would be difficult to justify an additional E/M service on top of the well-woman exam, even with thorough documentation. The physician's examination did not indicate any abnormalities, and there is no diagnosis other than 625.9 (unspecified symptom associated with female genital organs). After the patient returns for her ultrasound, the physician will review the findings and determine if other steps are needed. The ultrasound and any subsequent office visits will be billable services.

 

Case Study 2: A 55-year-old postmenopausal patient reports for her annual well-woman exam. She complains that since her last annual visit she has developed hemorrhoids and asks the physician to counsel her on osteoporosis prevention. The physician conducts the routine physical, including a pelvic exam, and does a digital rectal exam. During the rectal, he detects a lump between the vaginal and rectal wall, which he did not notice during the pelvic exam. He schedules a DEXA bone scan for a later date and writes a prescription for hemorrhoid cream. The physician schedules the woman to return in one week for an ultrasound and tells her that a biopsy may be necessary.
 
Coding the Case: The well-woman portion of the visit would probably be coded 99396 (periodic preventive medicine reevaluation and management ... established patient; 40-64 years).
 
Coding the well-woman portion of the visit is the easy part, but what about the patient's complaint of hemorrhoids, questions about osteoporosis and the discovery of the lump during the rectal exam? The visit took about 15 minutes longer than a typical well-woman visit, because tests were ordered, etc.
 
According to Witt, Case Study 2 involves only two separate problems. In this instance, osteoporosis counseling -- and how to prevent it in the absence of a diagnosis of osteoporosis -- is a preventive service and should be included in 99396. Until and if the DEXA bone scan reveals osteoporosis, there is no treatment for it, so the physician would not have performed a separate problem-related service.
 
Examination and treatment for hemorrhoids, 455.0 (internal hemorrhoids without mention of complication), are not significant enough to warrant an additional E/M charge because a rectal examination is part of the preventive service. However, when combined with the discovery of a lump, the picture changes, and an additional E/M service charge is justified.
 
Since the charge hinges on documentation, the physician will take an HPI (history of present illness) specific to the new problem of hemorrhoids. The physician will then document items such as how long they have been bothering the patient, what self-treatment she may have attempted and the degree of any pain she may have, etc. The result would then be an expanded problem-focused HPI and the review of a single, pertinent system, in this case, gastrointestinal.
 
Because the lump cannot be diagnosed currently, and the patient was unaware of it prior to the visit, there is no history to be taken. "So what we're looking at," Witt explains, "is the physician documenting additional history on the hemorrhoids alone, but the medical decision-making (MDM) is related to the lump." The MDM would show moderate risk and minimal data ordered. The MDM would also involve multiple diagnostic and/or management options, because the lump could turn out to be one of several different diagnoses. The risk is moderate due to the presenting problem, an undiagnosed new problem with uncertain outcome. It could be as serious as cancer, or it could amount to nothing. Minimal data were  available because an ultrasound had only recently been ordered, and there were multiple management options due to the variety of diagnoses that may be assigned to the problem once the workup is complete.
 
The combination of an expanded problem-focused history (extended HPI with a pertinent system review) required for a level-three E/M visit and a MDM of moderate complexity required for a level-four E/M visit would most likely be coded 99213 (office or other outpatient visit for the evaluation and management of an established patient ... ) with modifier -25 appended. This E/M service will be linked to the diagnosis code for the lump, 625.8 (other specified symptoms associated with female genital organs). This code is the most accurate without more information.
 
"Given the current case description," Witt says, "the visit would probably not qualify for a 99214; however, depending on what the ultrasound reveals, future visits to deal with the lump may. If the physician had documented a detailed history instead, then the documentation would most likely support 99214." 
 
In any case, because the physician was able to document two of the three key components of an E/M service that were clearly unrelated to preventive care, the additional service is a justifiable, billable service. The patient's record must clearly state the extra work completed, and you should be prepared for some payers to balk at the E/M service combined with the preventive service. Also, be ready to show documentation from both CPT and the physician's notes to justify the charges.