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GYN Exam Only

  1. #1
    Overland Park, KS
    Default GYN Exam Only
    Medical Coding Books
    I'm going to throw this question out here to see what other opinions might be....I have a female patient who presented to the office for her annual pelvic exam. The provider performed the pelvic exam and obtained a pap smear.

    My question is this....would this be coded as a preventive E/M or as a regular Office/Outpatient E/M (99201-99215)? My providers all want to use a preventive E/M, but I say it should be coded from the 99201-99215 category. Preventive exams are supposed to be comprehensive. If the provider is only performing the GYN only, then this is not comprehensive, but a single organ system exam and since the GU component of the 1997 guidelines has a bullet for a pelvic exam, I say it is included in the 99201-99215 code.

    Dawson Ballard, Jr., CPC, CEMC, CPMA, CCS-P, CPC-P, CRHC, AAPC Fellow

  2. #2
    I would go with preventive.

    Comprehensive in the preventive visits is not the same as the problem visits. It is age and gender appropriate. So there is no defined amount of work that must be done.

    Also, with the problem visits you need a problem. This is an annual screening so it doesn't meet that requirement.

    Just my take on it,

    Laura, CPC, CPMA, CEMC

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