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Ob-Gyn Coding Alert

Reader Question:
Use -52 With Preventive Visit for Medicare Only

Question: A 34-year-old patient comes in for her yearly exam, and the doctor finds a breast mass. The patient also complains of left lower quadrant pain. Should I code the preventive portion 99395-52 and reduce the fee and then bill 99213-25?

Oklahoma Subscriber Answer: As long as the ob-gyn sufficiently documents both the preventive exam (99395, Periodic comprehensive preventive medicine reevaluation and management of an individual ... 18-39 years) and the problem-oriented E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...), you can report both codes with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213.
But, you should add modifier -52 (Reduced services) to 99395 only for Medicare patients. Medicare requires you to carve out the covered service from the noncovered service, meaning you have to take all the components of the preventive visit out of the E/M service and then decide if you still have sufficient documentation to support reporting a separate problem-oriented visit.
Many private payers, however, do not apply this rule. You can bill them your full fee for the preventive service and your full fee for a problem service.

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