Pediatric Coding Alert
Pelvic Exam Code Hinges on Reason, Payer
New York Subscriber
Answer: To decide if you should separately code the pelvic exam, check whether the pelvic exam is problem-related, and check the insurer.
Reason: Because no CPT code describes a pelvic exam, there is no way to separately report the routine procedure using CPT codes. The insurer will probably include the routine pelvic exam in the well visit. So if you perform the pelvic exam without a patient complaint, you would instead code only the preventive medicine service. Use 99384 (new patient, ages 12-17), 99394 (established patient, 12-17), 99385 (new patient, 18-39) or 99395 (established patient, 18-39) with a diagnosis of V20.2 (Routine infant or child health check) or V70.0 (Routine general medical examination at a healthcare facility).
You should, however, bill a separate E/M service if you address a significant medical problem related to the pelvic exam. In this case, you would report an E/M code for the problem-oriented work, as well as the appropriate preventive medicine service.
Example: A 16-year-old female patient who is under your care presents for her annual well visit and also complains of painful menstruation. For the history, evaluation and medical decision-making that relates to the painful menstruation, you should report 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 625.3 (Dysmenorrhea). The modifier designates the office visit as significant and separate from the well visit. You should also report the preventive-medicine service with 99394 linked to V20.2.
Don't forget: If the payer doesn't reimburse the Pap smear specimen preparation and handling with 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) and v72.31 (Routine gynecological examination), you may bill the patient for the charge if the contract considers lab collection a noncovered service.
Exception: Some insurers may accept a HCPCS level II code for a pelvic exam. For these payers, you may report S0610 (Annual gynecological examination; new patient) or S0612 (... established patient) linked to V72.31.
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