New Finding During GYN Preventative Visit: Incidental or Separately Billable?

[RCiscoObGyn]

Hey everyone,

I'm looking for some input from more experienced OB/GYN coders on this scenario that's been driving me bonkers. I'm very comfortable with using mod 25, but this particular situation always gets me arguing with myself and ready to chuck my computer out the window. I'd really like to hear how others interpret it.

Scenario: Pt presents for a routine GYN prev visit. During the exam, the provider palpates a breast lump, documents additional history related to the lump, performs a more targeted breast exam, switches mammogram from screening to diagnostic and/or orders ultrasound.

Question: Would you consider this a separately billable problem-oriented E/M-25, or do you treat all findings during a prev exam as incidental and part of the prev service? I'm specifically wondering how others draw the line between incidental finding vs. new problem discovered, evaluated, and managed during the prev. I realize something like N93.9 that is additionally evaluated and managed during the prev exam would clearly be separately identifiable and able to stand alone. While I'm coding prev clinics, I always ask myself, "If this were by itself in a separate note, could it stand alone as a billable E/M?", but this particular situation, and ones like it, feel eerily blurry. I'd really appreciate hearing how you all treat this situation during coding and/or auditing.

 

[kaylahcm@hotmail.com]

Seems to me that the provider, discovered an abnormal lump during a screening, and performed a separate exam with focus on the lump in the breast.
mdm: new illness w/ uncertain prognosis (malignancy must be ruled out), ordered ultrasound, changes in care. I would bill a separate visit.

my rule is

• They document it in the physical exam notes but take no action: There is no extra history gathered, no clinical risk assessment performed, and no medical decision-making executed; then not a separate visit.

 

[RCiscoObGyn]

Seems to me that the provider, discovered an abnormal lump during a screening, and performed a separate exam with focus on the lump in the breast.
mdm: new illness w/ uncertain prognosis (malignancy must be ruled out), ordered ultrasound, changes in care. I would bill a separate visit.

my rule is

• They document it in the physical exam notes but take no action: There is no extra history gathered, no clinical risk assessment performed, and no medical decision-making executed; then not a separate visit.

I moved to OB/GYN 7 months ago from gen surgery. I started as a coder in gen surgery, so I'm still fairly new to preventative coding. I absolutely love OB/GYN though; there's so much to it. Thank you for replying!