Results 1 to 4 of 4

Challenging Scenario

  1. #1
    Talking Challenging Scenario
    Exam Training Packages
    I am looking at some claims for an OB/GYN practice. One of the situations is this.

    33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".

    She counseled the patient regarding the findings, possible diagnoses, and possible treatment options. She documented the discussion and time spent very clearly.

    The patient decided to have surgery the following Monday. The patient returned to the clinic a third time (the same date) with her husband. The doctor explained the results of the testing's and exam to the patient and her husband answered all of their questions and documented the start and stop times of the visit. I am posting what she coded and then what I think it should be coded as and I would like your opinion.

    Provider Coding
    1st visit same date:
    CPT DX
    99395 V72.31
    99213 V72.31; 620.2; 625.3; 250.00
    76830 620.2
    81002 V72.31

    2nd visit same date:
    99213 789.33; 625.3; 250.00; 218.9
    76830 789.33

    3rd visit same date:
    99215 625.3; 250.00; 218.9 752.11; V26.49; V72.83

    She did not use any modifiers.

    I believe it should be coded as follows. My only concern is that the rules say not to bill prolonged care with a preventive medicine visit. I think in this case it is OK because there is a separate E&M code. The total time spent in counseling is 90 minutes. Please let me know what your opinion is.

    Visit 1 (Claim 1)
    CPT DX
    99395 V72.31; V76.47; V73.81 (she did provide these services) 625.3
    81002 V72.31

    2nd & 3rd visit same date (because all of the appropriate diagnosis codes will not fit on one claim)

    99215-25 789.33, 625.3, V72.83
    99354 789.33, 625.3
    76830 789.33
    76830-76 789.33, 625.3, V72.83

    I want to use this case in my advanced E&M coding course and want more than my opinion on the accuracy of the coding. Please let me know what you think.
    Mickie Kummer, CPC, CPMA, CRC, CPC-I, AAPC Fellow

  2. #2
    Default
    I think the provider coded the first visit correct expect a modifier 25 is needed on the 99213. The CPT book states that if an abnormality is encountered in the process of performing a preventive medical examination and the problem is significant to require additional work then the approriate E&M should also be reported with modifer 25 added to indicate a signifcant & seperate E&M service.

    Was the third visit on the same day as surgery? that is pre op then.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default 3 visits in one day
    If I understand your scenario correctly the patient came to the office three separate times in one day ... Visit # 1 preventive with discover of mass ... Visit # 2 ultrasound and discussion of treatment options ... Visit # 3 counseling (along with husband) re surgery risks, benefits, outcomes, etc.

    If I have that right, then I agree with your coding (though I didn't check the ICD-9 codes).

    You would roll all the work of "sick" visits together and code the 99215 plus appropriate prolonged service as time is documented. You will need a -25 modifier on the 99215 and on the prolonged services code(s).

    If these visits are within 48 hours of the surgery you'll probably also need a -57 modifier.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Location
    Columbia, MO
    Posts
    12,569
    Default
    Quote Originally Posted by m.j.kummer View Post
    I am looking at some claims for an OB/GYN practice. One of the situations is this.

    33 year old female presented for her annual GYN check and to discuss birth control methods versus sterilization. Pretty routine preventive medicine visit, very well documented. During the exam, the physician found a mass in the right adnexa. The patient had been experiencing painful periods and with the exam findings the provider decided to perform a Transvaginal ultrasound. She scheduled a time for the patient to come back later the same day for the ultrasound. During the ultrasound the physician found "abnormal adnexal masses" and a "Large right adnexal mass, solid in nature".

    She counseled the patient regarding the findings, possible diagnoses, and possible treatment options. She documented the discussion and time spent very clearly.

    The patient decided to have surgery the following Monday. The patient returned to the clinic a third time (the same date) with her husband. The doctor explained the results of the testing's and exam to the patient and her husband answered all of their questions and documented the start and stop times of the visit. I am posting what she coded and then what I think it should be coded as and I would like your opinion.

    Provider Coding
    1st visit same date:
    CPT DX
    99395 V72.31
    99213 V72.31; 620.2; 625.3; 250.00
    76830 620.2
    81002 V72.31

    2nd visit same date:
    99213 789.33; 625.3; 250.00; 218.9
    76830 789.33

    3rd visit same date:
    99215 625.3; 250.00; 218.9 752.11; V26.49; V72.83

    She did not use any modifiers.

    I believe it should be coded as follows. My only concern is that the rules say not to bill prolonged care with a preventive medicine visit. I think in this case it is OK because there is a separate E&M code. The total time spent in counseling is 90 minutes. Please let me know what your opinion is.

    Visit 1 (Claim 1)
    CPT DX
    99395 V72.31; V76.47; V73.81 (she did provide these services) 625.3
    81002 V72.31

    2nd & 3rd visit same date (because all of the appropriate diagnosis codes will not fit on one claim)

    99215-25 789.33, 625.3, V72.83
    99354 789.33, 625.3
    76830 789.33
    76830-76 789.33, 625.3, V72.83

    I want to use this case in my advanced E&M coding course and want more than my opinion on the accuracy of the coding. Please let me know what you think.
    MJ,
    I do agree with your coding but I have a couple of questions, Why did you code for a vaginal pap screening?, and why did you code for a repeat ultrasound? From the documentation I see only 1. Also you have 8 dx codes per claim and you cannot submit 2 claims for one day per patient they will hit as duplicates so you will need to put it all on one claim but you have 8 dx slots so it should work fine.

    Debra A. Mitchell, MSPH, CPC-H

Similar Threads

  1. Challenging Areas
    By oreyeszwirn in forum Rheumatology
    Replies: 1
    Last Post: 05-15-2015, 01:23 PM
  2. Challenging Areas
    By oreyeszwirn in forum Cardiology
    Replies: 1
    Last Post: 09-25-2014, 06:05 PM
  3. Challenging Areas
    By oreyeszwirn in forum Neurology/Neurosurgery
    Replies: 0
    Last Post: 09-22-2014, 07:37 AM
  4. Challenging Areas
    By oreyeszwirn in forum OB/GYN
    Replies: 0
    Last Post: 09-22-2014, 07:36 AM
  5. Challenging physicians
    By jewlz0879 in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 02-07-2013, 03:07 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.