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Annual gyne exam

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    I have a coding scenario where the patient is 50 years old, she comes in and the physician performs an annual gyn exam which includes her pap, pelvic, breast exam. The physician go over results which includes an abnormal DEXA and she needs to be put on a bisphosphonate. The time spend is more than time than just 99212 or 99213. I want to code and bill to get that time paid for. How do I?
    The physician spends more time explaining her graphs, interpreting them for her and discussing her risks and benefits of meds.

    Thanks!

  2. #2
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    Quote Originally Posted by Manas maity View Post
    I have a coding scenario where the patient is 50 years old, she comes in and the physician performs an annual gyn exam which includes her pap, pelvic, breast exam. The physician go over results which includes an abnormal DEXA and she needs to be put on a bisphosphonate. The time spend is more than time than just 99212 or 99213. I want to code and bill to get that time paid for. How do I?
    The physician spends more time explaining her graphs, interpreting them for her and discussing her risks and benefits of meds.

    Thanks!
    First off, I would start with why she came in. Did she come in for an annual? Did she come in for a problem visit and they did the pap/pelvic at that time? If she came in specifically for her annual, I would look at the preventive code 99396. If all the elements of the visit are there, that's the direction I would go. if she came in for a problem visit, you can only code what the documentation dictates. So, if the elements for a 99212, and the Dr. spends more time than that, then look at the prolonged visit codes. But just make very sure your documentation will support this.

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    Thank you very much!

  4. #4
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    for mdc pap and office visit, i usuall code G0101 and Q0091 and the office visit with -25 attached. mdc has been paying for this and i also use G0101 on commerical insurance when we do a pap and most insurance pays

    hope this helps
    Nickie, CPC

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