Primary Care Coding Alert

Question: Our office provides birth control start appointments for college-age women. The nurse practitioner or physician assistant obtains a history to verify that birth control is not contraindicated, but does not perform an exam. How should we code these visits?

Pennsylvania Subscriber

Answer: You can code these visits by basing the E/M code choice on one of two options. First, you could choose an appropriate level E/M code based on the history, exam, and medical decision making documented. Consider a second option if counseling (e.g., regarding dangerous versus trivial side effects, adjustment period, what to do about missed pills, remaining need for STD protection, etc.) dominates the encounter. If so, choose the E/M code based on the time spent face-to-face with the patient. The time involved with counseling may justify a higher code, even without a physical exam.

When coding for the services of an NP or PA, be aware of what state laws allow them to do within the scope of their licenses, as this may limit the level of service they can provide and you can report without a physician's involvement.