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Ob-Gyn Coding Alert

Test Yourself:

Coding Adolescent Reproductive Health Visits

How much have you learned about the critical aspects of coding adolescent gynecological exams? Try coding each of the following scenarios and then look in the box below to check your answers against those provided by coding experts. 1. A 16-year-old new patient comes in for an office visit, complaining of not having a period for three months. The physician diagnoses an eating disorder, severe bradycardia, hypotension, and hypothermia, and recommends admission to the hospital's eating-disorder unit. The physician takes a history and performs a complete physical except for a pelvic exam. The physician spends one hour and 40 minutes with the patient and her mother during this encounter. 2. An ob-gyn prescribes birth-control pills to an adolescent and wants to see her for follow-up in one month for a compliance check. The patient does not have a physical exam on her return visit. 3. An ob-gyn performs a colposcopy on a 17-year-old established patient. Abiopsy of the cervix reveals moderate cervical dysplasia. The physician reviews the results with the patient in the office a week later. The mother is extremely anxious and concerned. The physician does not re-examine the patient during the visit but counsels the patient and her mother for 45 minutes. 4. A 17-year-old established patient is scheduled for a colposcopy. On the day of the planned procedure, she also complains of a breast mass. The physician completes the colposcopy with cervical biopsy, takes a breast history, performs a breast exam, and discusses the breast findings and plan with the patient.  
1. You should report 99205 (Office or other outpatient visit physicians typically spend 60 minutes face-to-face with the patient and/or family) for the comprehensive initial outpatient problem visit (60 minutes in length) and link it to 626.0 for amenorrhea. Remember that the diagnosis of secondary amenorrhea is the absence of menstruation for at least three months. If the patient missed only one or two periods, you would link 626.8 (Other disorders of menstruation ...) to the service instead. Because the physician spent a total of 100 minutes with the patient and her mother, you can bill for any additional time that the ob-gyn did not spend performing the history, exam and medical decision-making. In this case, we will assume that the physician spent 60 minutes (the typical time listed for 99205) dealing with the elements of the E/M service. This means the physician can bill for 40 minutes of prolonged services time using code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; first hour). Note: You should use prolonged services codes (99354-99357) to bill protracted services related to the outpatient problem visit, [...]

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