Preventive Visit

motherzone

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Scenario
Medical Mutual is the Insurance
21 year old Female comes in the office - Notes state- "Her for annual pap no accute problems. Would like to learn how to do self breast exams". Physical Exam: Doctor checked General, Chest, Abdominal, GU-Female Checked, and did a pap smear".

The billers billed a CPT 99214-est pt OV, with a DX V723.1- Routine GYN. Well of course MMO denied the visit.

I am a coding claims specialist- I said that this needs to be a CPT 99395-Periodic comprehensive preventive medicine visit with the DX V723.1

Well I am getting a lot of static from another coder stating that the EM CPT 99214 is correct and that the CPT 99395 is not correct.

HELP- Please let me know what your opinions are on this issue.
:mad: :mad: :mad:
 

dmaec

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I agree with you motherzone, regardless of what insurance carrier! :) From the info you've given this appears to be a preventive service and pap. The codes I'd use would be: 99395 with V70.0 and V76.2 for the pap. Also, from the info given - if that's all that was given, this doesn't support a level 4 E/M!
I'm betting that the provider who marked the ticket that the billers entered, accidentally marked the wrong area and meant to mark the preventive service and NOT the E/M!
btw - that's why "we're" coders - and they're billers ;)
 

moshjl

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The Principals of CPT Coding book states "The codes for new and established patient preventive medicine E/M services (99381-99397) include counseling, (which showing a patient how to perform self-breast examinations would be counseling), anticipatory guidance, and risk factor reduction interventions (i.e., pap smears) that are provided at the time of the initial or periodic preventive medicine service. If an abnormality is encountered or a preexisting problem is addressed in the process of performing the preventive medicine E/M service, and the problem is significant enough to require additional work for the physician to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code (99201-99215) should be reported in addition to the appropriate code fro preventive E/M service. Modifier -25 should then be appended to the office/outpatient E/M.
Hope this helps!!
 
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