Forum - Questions & Answers

Oct 29th, 2014 - dlove1

New gynocologic patient defers exam

Hello,

We wonder how you would bill for a new patient for a gynocologist visit. The patient is 14 and is there for menorrhagia, which constitutes a problem visit but defers an examination. For a new patient you need 3 out of 3. We thought about doing a new preventive but it is clearly a problem visit. Can anyone give some insight on how to code this.

Thank you
Debbie

Oct 29th, 2014 -

re: New gynocologic patient defers exam

The Well Woman visit is only for patients coming in for their annual check up and there is no other symptoms. I would code this out as a N/P problem visit 99201-99205 depending on the documentation and medical decision making. I would have the physician document the time spent for counseling(face to face time) and treating the patient for the pertinent problem, sounds like a 99202 as long as counseling time is documented which is about typically 20 minutes and the provider should be very theral in his documentation, if it was less than 20 minutes 99201 is about 10 minutes and the MDM is usually straight forward in the treatment. I would then schedule the patient to come back for her WW visit. normanly you cannot bill for a WW vist w/out a gyn exam per the MCR guidelines.



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