Coding Corner: Seeing a New Patient and Performing a Procedure on the Same Day | Andrew Menzin, MD, MBA, FACOG, FACS
Consider the following scenario: a patent is seen in the office setting for a consultation related to a right ovarian cyst associated with pelvic pain. On examination, an area of white epithelium is noted on the left labia majora. The patient is agreeable with biopsy of the vulvar lesion, and it is performed. A discussion is then also undertaken regarding the proposed further evaluation and management of the ovarian cyst, with the disposition related to the vulvar finding deferred until the pathology is available.
In this scenario where the evaluation of an ambulatory patient warrants an office-based procedure, the ICD-10 codes selected should reflect the diagnoses that relate to the indication for the visit (right ovarian cyst [N83.201] and pelvic pain [R10.2]) as well as the findings necessitating the office-based procedure (vulvar lesion [N90.89]). The E/M level (9920#) should reflect all elements of the consultation, and the modifier (-25) should be appended to signify a procedure separate from the E/M service. The CPT code (vulvar biopsy ) for the procedure should be linked only to those ICD-10 codes that relate to the procedure itself. Note that if the patient’s evaluation were to warrant biopsy of additional vulvar lesions, a distinct CPT code (vulvar biopsy, additional lesion ) is used for this other sampling.
Depending upon the patient’s acuity and wishes, the procedure could be deferred to an alternate day at which time only the relevant ICD-10 and CPT codes would be used, without the need for a modifier.
Consider the additional scenario: a postmenopausal patient present for evaluation of postmenopausal bleeding. During the encounter, an endometrial biopsy is discussed and performed. The approach to coding would be similar to the previous example. The ICD-10 code for postmenopausal bleeding is N95.0 and the CPT code for the endometrial biopsy is 58100. The E/M selected should reflect the type of encounter (new versus established patient) and the level selected. The modifier (-25) should be employed as well.
Andrew Menzin, MD, MBA, FACOG, FACS is a gynecologic oncologist at Northwell Health in Manhasset, NY.