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Thread: Woman's physical vs. Well Woman Exam

  1. #1
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    Smile Woman's physical vs. Well Woman Exam

    his is a re-visit of a confusing scenario. We have an Internal med doctor that saw a female for an "Annual Assessment." The patient is 61, and non-Medicare. The patient has various chronic, but stable problems; and one new insignificant problem, Ear Dermatitis.

    As a part of her Annual, she had pelvic/breast exam and a pap smear. She also had a Blood Occult test, 82270, but it is not documented of when and where the card were given out. I think it is new patient exam. The notes read like a physical with a

    CPT: 99386; but what is the diagnosis?

    What is the difference between a woman's annual physical and a well woman exam?

  2. #2
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    Arrow

    I actually had the exact same question not too long ago over a similar situation - I had a pretty difficult time finding information on it. What I gathered was that there really is no specific definition of a routine exam, at least, not in the same way that there is for a problem oriented exam. Everything is centered around the age of the patient, and relevant risk factors specific to them. In reference to the requirements of the exam, the word "comprehensive" (for the history and exam) is not clearly defined, except to say that it isn't equivalent to the comprehensive nature of the office/outpatient E/M codes.

    The well woman exam did have a stipulation, though - the pelvic exam has to be performed. That's only because of the V72.31 definition "Routine GYN exam with or without pap cervical smear / Pelvic Examination (annual) (periodic)". Beyond that, there was a lot of controversy about exactly what all has to be done for an exam to be considered "well woman" (as opposed to just a general routine exam). The biggest debate was over whether or not a breast exam had to be performed - I believe it even varies from payer to payer (Medicare stopped requiring it in 2008, apparently). I did find this today: (http://www.acog.org/departments/codi...ngServices.pdf)

    It's actually pretty informative - the best answer I've been able to locate on the subject so far. Hope it helps, but fi you find anything better, let me know. I'm still not comfortable with my grasp of the subject.

  3. #3
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    Default Woman's Physical v. Well Woman

    Thank you for the input, and the link you attached is one of the better ones that I have seen. I have done a years worth of coding for an Ob/Gyn Clinic; and for them it was no brainer, you just used the V72.31 and/or the V76.2 plus any insignificant problem dx codes with the appropriate Well Woman CPT code.

    But in this case I have an Internal Med doctor, who listed an Annual Assessment. The patient had a few chronic but stable conditions like fibromyalgia and ear dermatitis. However, he also did a Pelvic and Breast exam as well as a Pap smear. This doctor listed a V70.0, adult physical exam; but this could easily be Gyn Well Woman exam because of the Pelvic/Breast/Pap.

    Debra Mitchell said if they did a Pelvic/Breast/Pap it is a V72.31. So, if that is true, that makes it easy. Her input is reliable, but I think there is more to look here. I am going to print out your link and re-read it. Thanks again and Merry Christmas.

  4. #4
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    That's freaky! Mine was almost the exact same situation, except they had billed a problem E/M with a V70.0, and were trying to get a pap paid separately... (It was a mess...) I was racking my brain trying to figure out if there was enough documentation to support a well woman E/M with an additional problem-oriented E/M, because she had current Rx management, and I wanted to try to get them reimbursed as well as possible. I ended up giving up...I couldn't determine where to draw the line at the "well woman" part, so I could try to calculate a level for the problem E/M - I didn't know how much would be covered under the preventive E/M, or how much information could be overlapped, and I didn't have a clue as to where to start. How do you appropriately separate 2 things that don't use the same measurement criteria? It's like trying to figure out how many gallons are in a kilometer.

    You have a merry Christmas as well!

  5. #5
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    Default Woman's Physical v. Well Woman

    I think what you just wrote is valuable. It gives me some directions to look into. How much of Pelvic/Breast exam do you need to code a well woman? Is the check list different for a Woman's physical. When I was coding for Ob/Gyn Clinic, there was just a long list of problems that dominated the visit, so I just turned it into a 99203 or 99214. The lab gets a little re-imbursement for the Pap anyway. I discussed with a couple of the OB/Gyn docs and they seems Ok with it.

    I wish that things were made simpler by saying only a Gyn could code and bill a Well Woman. That would be too easy wouldn't it?

    Btw...I am still confused on the dx code for Ear dermatitis. It seems to be 50/50 vote on it. I am going to see if the Coding Institute has anything on this dx.


    Merry Christmas...

  6. #6

    Default

    This link you have here does not work. Do you possibly have a new one? Our office is posed with the ? now of what is required in a preventitive visit in order to consider it a well woman. Is the breast exam and pelvic exam both required to consider it a well woman?

  7. #7

    Default OBGYN Preventative and Office visit

    I have been looking for info on this. my drs have been doing new preventative and then
    doing an established office visit on same DOS with a -25 modifier if they have had several
    issues beyond there yearly preventative visit. Can they charge a new Preventative and a NEW office visit on same day of service. Please HELP

  8. #8
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    Default

    If the documentation supports both then yes you can bill both a preventative and an office visit but both codes shouldn't be for a new pt. I would bill the preventative as a new pt and then an established office visit code.
    Herbie W Lorona Jr., CPC, CPC-H
    hlorona@up2parmedicalclinic.com

  9. #9
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    Default

    Quote Originally Posted by btadlock1 View Post
    That's freaky! Mine was almost the exact same situation, except they had billed a problem E/M with a V70.0, and were trying to get a pap paid separately... (It was a mess...) I was racking my brain trying to figure out if there was enough documentation to support a well woman E/M with an additional problem-oriented E/M, because she had current Rx management, and I wanted to try to get them reimbursed as well as possible. I ended up giving up...I couldn't determine where to draw the line at the "well woman" part, so I could try to calculate a level for the problem E/M - I didn't know how much would be covered under the preventive E/M, or how much information could be overlapped, and I didn't have a clue as to where to start. How do you appropriately separate 2 things that don't use the same measurement criteria? It's like trying to figure out how many gallons are in a kilometer.

    You have a merry Christmas as well!
    Brandi-

    I am just seeing this post but the link you provided is now broken? Would you happen to have a new link or one that is not broken that you could send me. I am now going thru this issue with my OB/GYN group saying they are doing a manual exam and a breast exam, no pelvic and they state this is a well woman visit and not an annual gyn because no "internal" is done.

    I am looking for guidance on the difference between S0612 and S0613?

    Any suggestions.

    Thanks,
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  10. #10
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    Default

    2017 ICD-10-CM Coding Book
    The link will not work.

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