when is wet mount coded in the office visit?

[RABBIT2020]

Based on this documentation is there any possible reason to bill for the cpt 87210?

Gyn Exam: ABDOMEN: soft, non-tender, no masses or organomegaly. VAGINA: normal, no lesions; BV probe obtained. Assessments 1. Acute vaginitis - N76.0 (Primary) 2. Acute cystitis without hematuria - N30.00 Treatment 1. Acute vaginitis Start Nuvessa Start Macrobid Capsule, LAB: *Vaginitis/Vaginosis, DNA Probe BV Clinical Notes: Check BV culture Rx Nuvessa for probable BV . 2. Acute cystitis without hematuria LAB: *CULTURE URINE Clinical Notes: UTI Sx + Leuks on dip Check urine culture Rx MB x 5 days Manage pending culture results

 

[csperoni]

87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps)
Did you provider prepare and INTERPRET the slide specimen? In my area, the physician always sends to pathology and is not interpreting personally. I have never worked with a physician who was doing his/her own pathology, but it is certainly possible. From the information provided, I do not see any interpretation of the slide.

 

[RABBIT2020]

There is no documentation to support that a wet mount was performed, however, the instruction by the lead coder is to code a wet mount for every vaginitis assessment.

 

[csperoni]

That sounds like a blanket policy made by someone who does not understand coding. It would be like saying "every new patient is 99204." All coding should be based on the documentation.
87210 requires not just the slide preparation, but interpretation. From the documentation, I see neither.
I would absolutely question this instruction, first privately and cordially with the person giving the instruction, and then up the ladder if needed. Starting with a "Hey, I know you're busy, but I don't fully understand this. Could you please explain it to me and provide some references I could review?"