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Code This!

Scenario Week of February 09, 2010:
View Current Scenario

Case Study:
A 45-year-old female patient calls a new internal medicine physician to schedule an annual well-woman checkup with routine pelvic exam. The office indicates that their policy is to perform the preventive exam on the first exam and that the patient must return a week later for the pelvic exam.

January 15, 2010
The patient presents for an initial well-woman exam. She is a 45-year-old white female in apparent good health. Review of her health questionnaire is significant for rosacea treated with a topical cream and seasonal allergies. Review of all other systems is negative. The patient is not married, is employed full-time, and has no children. Father died at age 78 from MI, mother still alive and in apparent good health. Siblings with no major health issues. She does not smoke and drinks only occasionally. Immunizations are current.

Exam

  • Constitutional: Blood pressure 118/80, pulse 60, respirations 34, height 68”, weight 145 lbs. She is well-developed, well-nourished, in no apparent distress
  • Eyes: PERRLA, no evidence of disease, does wear contacts
  • ENMT: Ears are clear, normal nasal mucosa, good dentition without obvious caries
  • Neck: Thyroid without masses, nontender.
  • Respiratory: Clear to auscultation bilaterally, normal respiratory effort
  • Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Pedal pulses intact, no edema of the extremities.
  • Chest/Breast: Breasts normal, no masses or lumps appreciated on manual exam. No discharge or pain.
  • Lymphatic: Lymph nodes of neck and axillae normal
  • GU: Deferred
  • Gastrointestinal: Normal bowel sounds. Abdomen soft, nontender, liver margin palpated.
  • Musculoskeletal: Normal gait, joints move within normal range of motion. Good muscle strength.
  • Neurological: DTR normal, sensation intactSkin: Warm to the touch, rosacea of the face
  • Psychiatric: Dressed appropriately, mood and affect appropriate. No indication of memory loss.

Impression
Healthy female patient
Script written for MetroGel 1%, will follow up with dermatologist for ongoing treatment
Patient to schedule mammogram within the month
CBC and comprehensive metabolic testing ordered as baseline

Patient to return for pelvic exam and Pap smear at a later date


January 22, 2010
Patient returns for pelvic exam and Pap smear

History is unchanged from visit 01/15/2010

  • Genitourinary: Normal external genitalia without masses or lesions. Speculum is inserted without difficulty. Mucosa normal. Cervix normal without lesion. Uterus normal size and position. Pap smear collected and prepped for transport to lab.
  • Lymphatics: No abnormal lymph nodes of the groin
  • Gastrointestinal: Normal anal sphincter, no masses or hemorrhoids

Impression
Gynecological exam, normal
Pap smear obtained and sent to lab

Return to clinic in one year or sooner if problems

Assign the correct CPT and ICD-9-CM codes for the procedure above.


CPT
January 15, 2010

  • 99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
  • 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
  • 80053 Comprehensive metabolic panel

January 22, 2010

  • G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination
  • Q0091 Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

CPT Rationale
The codes listed above are correct; however,l the practice incorrectly billed this service as:

January 15, 2010

  • 99386 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
  • 85025 Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count
  • 80053 Comprehensive metabolic panel
  • 99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. [Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service]

January 22, 2010

  • 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

For the visit on January 15, it is appropriate to bill the preventive medicine visit for a new patient with code 99386. However, in this circumstance it is inappropriate to report the separate E/M service, 99213-25. Guidelines on page 31 of the Professional Edition of CPT 2010 state:

“If the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the Office/Outpatient code 99201-99215 should also be reported.”

The treatment of the rosacea is minimal. The history does not specifically address the rosacea as a problem to be treated but is an element of the review of systems. In addition, the exam only notes rosacea, but does not give any qualities or appearance. Guidelines on page 32 of the Professional Edition of CPT 2010 further state:

“An insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-orient E/M service should not be reported.”

The supplied documentation does not indicate that additional work or key elements were required outside of writing a prescription to continue with an existing medication.

The visit for the sole purpose of performing a pelvic exam and obtaining a Pap specimen does not meet the qualifications of code 99215. The history is stated to be unchanged from the visit one week prior. The exam would be problem focused, and the medical decision making would be minimal. The pelvic exam and obtaining of the Pap smear would be most similar to KOH prep in the table of risk. There is not a problem oriented diagnosis and the most appropriate E/M service would be the established patient preventive medicine (99396) with a 52 modifier to indicate that a comprehensive history and exam were not performed. Note that many payers may pay only one preventive visit within a 12-month period. If the pelvic exam is reported as a separate service, the most appropriate codes are G0101 and Q0091 for obtaining and prepping the Pap smear.

The physician did not document time or counseling and coordination of care; therefore, time cannot be a factor in selection of an E/M code. Counseling for risk factors or behavioral changes should be reported with 99401-99412.

It is important to note that CPT states that the well-woman/preventive medicine encounter includes a comprehensive exam that “reflects an age and gender appropriate history/exam.” To separate the pelvic exam as a standard practice is not appropriate. Several specialty societies indicate that the pelvic exam is part of the age and gender appropriate exam for a woman in her mid-forties. When the patient is asked to return at a later date for screening examinations because of office policy or physician convenience, the service may not be reported as a problem oriented E/M service. Some payers who do not cover HCPCS codes G0101 and Q0091 may not pay separately for this service.

If this patient had been a Medicare beneficiary, the annual well-woman exam is not reportable. However, Medicare will cover G0402 Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment, known as the IPPE. In addition, Medicare will cover G0101 and Q0091 at the same visit with the appropriate diagnosis codes.
For most Medicare beneficiaries who have been enrolled longer than 12 months, the health maintenance components are completed in conjunction with a problem oriented E/M service. Screening examinations may be reported separately when performed in accordance with accepted frequencies.


ICD-9-CM

January 15, 2010

  • V70.0 Routine general medical examination at health care facility
  • V76.19 Other breast screening examination
  • 695.3 Rosacea

January 22, 2010

  • V72.31 Routine gynecological examination
  • V76.47 Special screening for malignant neoplasms, vagina

ICD-9-CM Rationale
January 15, 2010
Code V70.0 is used to report a “health checkup” according to ICD-9-CM. As this was a well-woman visit, this is the most appropriate first-listed code. Additional instructions indicate that other special screening examinations are also reported. The breast screening is reported with V76.19. This is a manual examination. Code V76.10 is for an unspecified screening and V76.11 and V76.12 are used to report screening mammograms.

As the physician noted the rosacea and refilled the patient’s prescription, it would be appropriate with this well-woman exam to report the diagnosis code for this minor condition.

January 22, 2010
The purpose of this visit was the pelvic exam and Pap smear. Code V72.31 is used to report the routine gynecological examination, and guidelines indicate that this code is for the “Pelvic examination (annual) (periodic). Guidelines also indicate that additional codes should be used to identify routine, vaginal Papanicolaou smear (V76.47).

Although the encounter for this day was reported as a problem oriented E/M service, there was not a problem oriented chief complaint or examination performed. It would be inappropriate to refer to a problem list or the history of rosacea as a diagnosis for this encounter as they were not documented nor treated.

 
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