Ob-Gyn Coding Alert

Many surgical procedures done in the ob/gyn office are billed using CPT codes that are called starred procedures. Since the starred procedure definition indicates that the code describes the procedure only, ob/gyn coders often are not certain if an E/M code can also be billed along with the procedure.

The surgery guidelines section of the CPT manual defines the concept of a starred procedure. Here are several different situations that may occur with a starred procedure:

New Patient Visit With a Starred Procedure

If a starred procedure is performed at the same encounter as a new patient visit, both may be reported. No modifier should be needed on the E/M service in this case. The guidelines in the CPT manual recommend using code 99025 (initial [new patient] visit when starred surgical procedure constitutes major service at that visit) in lieu of a new patient E/M code, but many ob/gyn practices find that this code does not adequately describe services, and many payers do not recognize this code. (See the May 1999 issue of OCA, page 35, for further details concerning 99025.) The documentation should support that a significant and separately identifiable service was done in addition to the procedure.

Established Patient Visit With a Starred Procedure

If the starred procedure is scheduled to be performed on an established patient, and the reason the patient presents to the office that day was specifically for the procedure, an E/M service would not be billed in addition to the procedure.

However, the established patient may come in with complaints that need to be evaluated, and then as a result of the examination and work-up, a starred procedure is recommended and is done at the same encounter. In this situation, both the E/M service and the procedure may be reported even if the diagnosis linked to both codes will be the same. A modifier -25 would be added to the E/M code in this case to indicate that the E/M service was significant and separately identifiable from the procedure. It is wise for the physician to get in the habit of creating a separate E/M and procedure note in the record. If the initial claim for either the procedure or the E/M service is denied, this documentation will clearly show the payer on appeal that the E/M service was separate and significant from the procedure performed that day.

Coding Example

A patient already established with the practice comes in with complaints of abnormal uterine bleeding. The ob/gyn completes the history associated with this complaint; examines the patient, and renders a plan of care. That plan of care includes an endometrial biopsy, which is done at this patient encounter. Both portions of the visit (the exam portion as well as [...]