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Coding questionFrom: RModugno@aol.comSat May 10 06:59:23 2008
>From ACOG: Is it possible to be reimbursed for an endometrial biopsy when it is being performed at the same time as a consultation? If so, how should it be coded? Topic: endometrial biopsy bundling Conf: _CPT/ICD9 Coding and Reimbursement_ (http://www.acog.org:8080/confinfo?4) From: _Savonne Montue_ (http://www.acog.org:8080/userpeek?49258) (_smontue@acog.org_ (mailto:smontue@acog.org) ) Date: Friday, January 06, 2006 09:07 AM Both the E/M service and the endometrial biopsy can be reported as long as you document that the consultation was “significant and separately identifiable †from the endometrial biopsy. According to CPT, a consultation must include a documented request from another physician that you render an opinion about the evaluation or management of the patient’s problem. You must send the requesting physician a report that discusses your findings and recommendations. You also may bill for diagnostic and therapeutic services performed during this visit. Report the appropriate level of office consultation (99241–99245) with a modifier 25 (significant, separately identifiable E/M service on same day as procedure). The endometrial biopsy is reported using CPT code 58100. Be sure to document the biopsy in a distinct procedure note separate from the E/M service note. You may use the same ICD-9-CM diagnosis code for both the E/M service and the biopsy. ++++++++++++++++++++++++++++++++++++++++++++++++ Robert Modugno MD MBA FACOG Sylva, NC
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