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Wiki Annual Gyn Exam & Problem Visit?

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mcdream

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Hello Gyn Coders- When a woman is seen for her annual exam and presents with a NEW gyn-related concern, are these considered included in the annual 993XX or do you bill a separate problem E/M? I know somethings don't support a separate E/M because they are considered inclusive/coincide with annual i.e, Rx for BC, ordering screenings for STI, mammo, etc... But what about the following examples when supported with HPI & MDM (ordered labs, or Rx given)?
-new onset foul vaginal discharge- suspect BV ordered vag pathogens lab
-new onset hot flashes- suspect starting menopause ordered labs
-new onset painful intercourse- Rx estrogen cream initiated
-new onset irregular menses- Rx OCP initiated
-new onset vaginal dryness- Rx estrogen initiated
-new onset menorrhagia- Discussed options IUD/Nexplanon & pt will return for implant
-new onset symptomatic menopause- Rx HRT initiated
Any advice is appreciated!
 
I would also bill the significant, and separately identifiable E&M service with -25.
You may have some carriers that pay a reduced rate, or even some that may not pay at all. That is part of their policy and/or your contract. However, the services were provided and should be coded appropriately.
 
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