Primary Care Coding Alert

Question: One of our doctors wants to know how to report services if a patient is seen for a specific problem and requests an incidental breast exam or Pap smear. There are no reasons for the exam, other than that the patient hasnt had one in a while. Should we use a preventive medicine code? Or is there a better way to code this?

Jean Sodowski
Seattle

Answer: Generally speaking, preventive codes (99381-99387, new patient or 99391-99397, established patient) entail more than a breast and Pap exam. They require a thorough assessment of the patients health. If no x-rays or labs were done during this visit, the practice would simply assign the evaluation and management code that reflects the level of service provided.