Wiki Annual Physical Exam & renewal of birth control

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Michael0630

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I have a question,

My OB providers see a lot of patients for Physical exams and then they will also renew patients birth control as well. My question is is it appropriate to bill 9938-9939 with also an e/m with diagnosis Z30.41?

I thank you in advance.
 
Michael0630 said:
I have a question,

My OB providers see a lot of patients for Physical exams and then they will also renew patients birth control as well. My question is is it appropriate to bill 9938-9939 with also an e/m with diagnosis Z30.41?

I thank you in advance.
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In most situations, renewing OCP during an annual preventive visit will not be sufficient to bill both a preventive and a problem oriented E&M. In order to do so, -25 is needed on 99202-99215. If you were to take the documentation and cross out everything related to the preventive well woman exam, is what you have left "significant"? For straightforward renewals, I would not imagine so. Perhaps if the patient were having issues - breakthrough bleeding, heavier menses, etc. and the provider documented and discussed this and perhaps changed the medication, you MIGHT have a 99202-99215 with -25 modifier.
 
Birth control management is not part of her annual preventative visit. You can definitely bill a e/m level with the physical code as long as you have the modifier -25 with it. See if the doctor will give you time as well, if they specify that the time for the birth control management was not included in the physical time, that might help you know which level to use also.
 
mmckibbin said:
Birth control management is not part of her annual preventative visit. You can definitely bill a e/m level with the physical code as long as you have the modifier -25 with it. See if the doctor will give you time as well, if they specify that the time for the birth control management was not included in the physical time, that might help you know which level to use also.
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Both I and ACOG will have to disagree. Birth control discussions are certainly included as an integral part of a preventive medicine service when indicated. Only if the patient presents with significant problems that had to be evaluated because of the use of birth control would a problem service be warranted at the time of the preventive visit. And as many on the forum have carefully pointed out - take away all of elements that are related to the preventive service to see it you still have anything significant to bill that would warrant reporting the service (with, as you have indicated, a modifier -25 added to the significant problem service).
 
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