Forum - Questions & Answers

May 28th, 2015 - MHYETT 5 

medicare coding

I have a new patient, hasn't had routine GYN exam in over 3 yrs. Now having p.m. bleeding issues, and during extensive visit, endo bx was done... How should this be coded?? G0101-GA, Q0091-GA, 58100-59 ?? or add 25 mod on G0101 also? This patient was with the Dr. a very long time face to face. Thanks for any input...

May 29th, 2015 -

re: medicare coding

If during the examan an abnormality was found or a pre-existing problem is addressed at the time of a preventive visit, this additional service is reported using a problem oriented E/M code. The additional services must be significant and separately identifable and the E/M level of service reported must be consisitent thie the key components perfomed in the evaluation of the problem. per your note is states the provider spen a long time face to face with the patient. If he/she documents the total time spent counseling/coordintion of care and a description of the content of the counseling and or cooordination of care activiities he may bill for an additional E&M service. Your codes should look as such.

G0101-GA, V76.2
Q0091-GA, Vv6.2
9920X-25 Dx code
58100, DX code

May 29th, 2015 - MHYETT 5 

re: medicare coding

Thank you for confirming....much appreciated.

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