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Preventative Visit for Well Woman exams

  1. #1
    Exclamation Preventative Visit for Well Woman exams
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    My physicians are following the guidelines in which a Pap is done every two years. Here's my delima. If a pap/pelvic exam is not done and just a breast exam, then it's my interpretation that this is just an Office visit 99213- 99215 and not the preventative E & M codes. My docs say that they can bill for example a 99395 with V76.2 & V72.31 because they are following these guidelines even though in the chart note under "genitalia" it says "Not Needed". If they are doing the pap/pelvic exam every 2 years then they should only be billing the preventative exam codes every two years. If I'm correct and I think I am, where can I find documentation to present to my Docs? Any help would be greatly appreciated.
    thanks,
    susan G

  2. #2
    Default Preventative exams
    Quote Originally Posted by sgormsen View Post
    My physicians are following the guidelines in which a Pap is done every two years. Here's my delima. If a pap/pelvic exam is not done and just a breast exam, then it's my interpretation that this is just an Office visit 99213- 99215 and not the preventative E & M codes. My docs say that they can bill for example a 99395 with V76.2 & V72.31 because they are following these guidelines even though in the chart note under "genitalia" it says "Not Needed". If they are doing the pap/pelvic exam every 2 years then they should only be billing the preventative exam codes every two years. If I'm correct and I think I am, where can I find documentation to present to my Docs? Any help would be greatly appreciated.
    thanks,
    susan G
    In this case, use the modifier -52 Reduced Services attached to 99395, as long as the remainder of the exam qualifies as preventative. The rationale for this is explained in the AMA's Coding with Modifiers Guide by Deborah Grider. It would not be appropriate, however, to use V76.2 & V72.31, because neither the gyn exam nor the PAP were done. I would use V70.0 and possibly V76.19 for the breast exam. I am interested to know how others would approach this.

  3. #3
    Default Preventative vs E/M
    If the physician is only doing wellness I would hesitate to code 99213-99215 because these are primarily illness codes (What would be your HPI?). It is possible that claims systems would not allow this anyway. I would stick with the cpt for preventative care and use the 52 modifier. The dx would be v70.0.

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