Wiki E/M Level for New Patient Birth Control Start

[jennifert@whcg.org]

One of my providers is stating that for all New Patients that are seen for request for Birth Control, specifically speaking about OCP's, those visit should be a 99204 d/t risk. I understand that a patient may have non-gyn related dx's that are managed by another physician that would be applicable and therefore the risk would be increased and/or other medications that would too increase risk. However I am not so convinced for those healthy patients that are being seen for birth control all fall into 99204. Example: Healthy 18yo presents for birth control. OCP's , Injectables, IUD/S's, Implants, etc are discussed with the patient along with risks associated with such devices/drugs. Admittedly they are not spending 45min or more with the patient during these visits, so billing based on time doesn't get them to a level 4. My provider has discussed this such senario with a fellow OBGYN she recently graduated with and they are using a level 4 for all birth control initiation visits. They've also spoken to several local providers, both OBGYN's and FP's all of which are stating they always bill a 99204 for New Patient Birth Control Visits. My physicians states that these visits should all be considered "undiagnosed new problems" with "prescription management" thus all should be a 99204 visit. Otherwise if not a "undiagnosed new problem" it should be identified as "Chronic Fertility". Can anyone provide and documentation of what is the appropriate way to dissect these visits. Thanks!

 

[csperoni]

While the RISK is moderate for prescription management, you would need also moderate problem or moderate data to get an overall level 4.
Per the AMA guide:
Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
I have seen examples like breast lump or significant abdominal pain. I don't see how a patient without a problem could possibly be considered this.
A healthy 18 y/o without any complaints and no testing ordered or reviewed is simply not 99204.
If the documentation indicates 1 chronic stable problem, the problem is low, Low problem, straighforward data, and moderate risk gets an overall level 3.
Any coding advice that says "always bill [this level] for [this problem or treatment]" is highly suspicious. One patient may be getting OCP just to prevent pregnancy. Another may be getting OCP due to abnormal menses. And the next due to very heavy bleeding causing anemia. They all have the moderate treatment risk of prescription drug management. But different levels of problems, resulting in different E&M levels.
Or a 46 y/o with HTN and menorrhagia being prescribed OCP may not be the same overall level as a 20 y/o previously on OCPs wanting a renewal.
I would dissect these visits like all E&M services - what is the problem level, data level and risk level? You must meet 2 of the 3 categories to code that level.

 

[Cmama12]

Sadly I have seen practices try to blanket code these types of visits... Further to what Christine said, per ACOG if the patient comes in knowing they want an IUD etc then a separate E&M may not be billable at all.

https://www.acog.org/education-and-events/publications/larc-quick-coding-guide/em-services-code-and-procedure-code

Here is also a coding guide from the RHNTC that also references ACOG - for their example of a new patient they code 99202.

https://rhntc.org/sites/default/files/resources/rhntc_smvst_contra_coding_ex_job_aid_1-28-2022.pdf

 

[jkyles]

Hi there, I echo the warning against "Always" coding, even if other providers are always doing it. As noted above, that is not the advice that ACOG has issued.

In addition, the more providers who always code certain visits as a high level visit the more likely it is that payers will focus on those kinds of claims for additional action, such as denials or post-payment review. Also keep in mind that if a payer were to deny or downcode your practice's claims, you would not be able to use the advice of other providers as a defense during your appeal.

 

[kdlberg]

I agree with all of the above. But I'm also curious about what dx code(s) are they attaching to these visits. What is the "undiagnosed new problem"? If it's a problem, it needs to have a code. If it doesn't have a code, it can't be a diagnosis.

 

[Kristina H.]

I would also ask them what differential diagnosis are they using that fits the CPT definition of "Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment." The diagnosis for these visits that are otherwise healthy would be Encounter for Contraception Management and/or Initial Contraception Rx. I do not see how NOT getting birth control would result in a high risk of morbidity. These problems are usually things like breast lumps, where the differential could be malignant neoplasm. It seems to me like they are not thinking of the Problem Addressed correctly from a coding perspective, even though the Risk could be a Level 4. My thought would be that "Patient would like to Initiate Birth Control" more so fits an Acute Uncomplicated Illness or Injury. Even if the problem is "Chronic Fertility", this is stable chronic Low Level. If the patient THEN had side effects and complications from the birth control, the problem addressed at the subsequent visits could possibly fit a higher level of care.

 

[Kelly_Mayumi]

I'm curious, does anyone have an opinion using the counseling codes, 99401- 99404, for scenarios like this, in healthy patients without any problems

 

[csperoni]

I'm curious, does anyone have an opinion using the counseling codes, 99401- 99404, for scenarios like this, in healthy patients without any problems

Hmmm, that is an interesting idea. I've never seen anyone use 99401-99404 for OCP prescription visits, but that doesn't mean it's incorrect.
Certainly 99401-99404 are not even a consideration for patients receiving OCPs for a medical indication.
I see no reason they could not be used when the visit for OCPs is purely preventive counseling. In the real world, I don't think you'll get the provider in the original post claiming the visit is 99204 to agree that 99401 is more appropriate. Particularly if they are concerned about the value associated with the code. While you should never determine coding based on the value, I think E&M 99202-99215 with Z30.011 or Z30.41 are the most appropriate codes for these situations. What I disagree with strongly is the providers insisting it's always a level 4.

 

[medicalauditor]

I'm curious, does anyone have an opinion using the counseling codes, 99401- 99404, for scenarios like this, in healthy patients without any problems

A visit specifically and only for contraception would not be an E/M visit, it is a preventive medicine counseling service - 99401-99404. The contraception is for preventing conception. There is no illness, disease or injury here. The visit does not become a problem-oriented E/M service (99202-99215) simply because there is a prescription.

 

[medicalauditor]

Hmmm, that is an interesting idea. I've never seen anyone use 99401-99404 for OCP prescription visits, but that doesn't mean it's incorrect.
Certainly 99401-99404 are not even a consideration for patients receiving OCPs for a medical indication.
I see no reason they could not be used when the visit for OCPs is purely preventive counseling. In the real world, I don't think you'll get the provider in the original post claiming the visit is 99204 to agree that 99401 is more appropriate. Particularly if they are concerned about the value associated with the code. While you should never determine coding based on the value, I think E&M 99202-99215 with Z30.011 or Z30.41 are the most appropriate codes for these situations. What I disagree with strongly is the providers insisting it's always a level 4.

I disagree that E/M codes 99202-99215 are the most appropriate codes. An E/M service would require an illness or injury which needs to be evaluated and managed. You have to be able to classify the illness as acute, chronic, chronic with exacerbation, etc., in order to call it a problem-oriented E/M service. There is no disease or injury for an encounter purely to discuss contraception. The encounter is only to discuss how to prevent a pregnancy, and that is "Preventive medicine counseling and/or risk factor reduction intervention(s)" by definition, which is 99401-99404.