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Modifier Coding Alert

Reader Question:

Prove Separate Services; Append Modifier to E/M During Well-Woman Visit

Question: An established, high-risk 72-year-old Medicare patient presents to the office for her annual well-woman exam. The patient is menopausal and there is a family history of endometrial cancer. Before the exam, she tells the physician that she has had three episodes of bleeding in the past year that concern her. The physician performs the complete well-woman exam, but then performs a separate history and exam for the patient’s bleeding. He orders the patient to have an ultrasound at a local clinic and schedules the patient for a follow-up visit the next week for an endometrial biopsy. Can I code a separate E/M service in addition to the well-woman exam?

California Subscriber

Answer: If your encounter notes prove that the physician performed a significant, separately identifiable E/M service in addition to the well-woman visit, then you can code the E/M separately.

Best bet: Go back and check the encounter notes. If you find a completely separate E/M, then report the following codes and modifiers for this encounter with your Medicare patient:

  • G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) for the screening portions of the well-woman visit;
  • Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the Pap smear portion of the well-woman visit, if performed;
  • the appropriate-level E/M code based on encounter notes (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that the E/M service was separate from the well-woman exam.