Coding for OB/GYN
The most commonly used E/M codes for OB GYN include:
99202-99205: New patient office visit codes
99211-99215: Established patient office visit codes
It's important to note that the medical decision-making for
E/M codes is based on the following elements:
The number and complexity of problems addressed
The amount and complexity of data reviewed
The risk of complications, morbidity, and mortality
associated with the patient's condition
Proper documentation of the E/M visit is also critical, and
should include the following components:
Chief complaint
History of present illness
Review of systems
Past medical, family, and social history
Physical examination
Medical decision-making
By accurately selecting and documenting E/M codes, OB
GYN providers can ensure that they are properly
reimbursed for their services and comply
with coding regulations.
These codes apply to Preventative/Annual visits
ICD
,Z01.419 if everything was normal and Z01.411 if there
were abnormal findings.
CPT codes for Preventative/ Annual visits:
18-39 years new pt. 99385 and if an est. pt. 99395
40=64 new patient 99386 and est, 99396
65 years or > 993987 if new patient, and est, 99397
> 65 years99387, new patient and est. 99396
These are some billing and coding resources that may be
helpful. Please remember that preventative visits/annuals
are coded differently than routine follow up visits.
Billing and coding resources in CON, student resources.
Tip Sheet: Evaluation & Management Services.
Coding for Evaluation and Management: Answers to
Common Questions.
Outpatient E/M Coding Simplified
PAP SMEAR
,Chief Complaint (CC): Routine Pap smear.
History of Present Illness (HPI): A 54 year old female seen in the office today
for routine screening for PAP smear with HPV testing. MJ is alert and oriented,
dressed appropriately for the weather, well-groomed. Denies fever, fatigue,
pain, or weight gain or loss.
Reason for visit: Annual gynecological examination and cervical cancer
screening.
Last Pap smear: 12/2022 with normal results reported.
Symptoms: Patient denies abnormal vaginal bleeding, discharge, itching,
pelvic pain, or other symptoms.
Menstrual History: Last menstrual period (LMP): 9/2017. Cycle was typically
30, lasting 7 days, and regular.
Obstetric/Gynecological History: Gravida 4, Para 2. Last birth was
05/06/1995. No history of abnormal Pap smears, HPV, or other sexually
transmitted infections (STIs).
Sexual History: Patient is sexually active. Same partner for 38 years.
Past Medical History (PMH): Hysterectomy in 2018, HTN, Hyperlipidemia
Family History (FH): No History of breast or cervical cancer in the family.
Social History (SH): No Tobacco use, occasional alcohol use.
Medications/Allergies: Atorvastatin 40mg daily, Lisinopril 40mg daily
NKA
O: Objective
Vital Signs: BP 141/84 mmHg, HR 69 bpm, RR 16 breaths/min, Temp 98.1.
General Appearance: Patient is well-nourished, alert, and appears in no acute
distress.
Physical Examination:
Abdominal Exam: Soft, non-tender, no palpable masses or organomegaly.
Pelvic Exam:
External: Normal female external genitalia without lesions, erythema, or
discharge.
, Speculum Exam: Vaginal walls moist and healthy. Cervix appears smooth,
pink, and without visible lesions or irregularities.
Pap smear collection: Specimen for liquid-based cytology and HPV testing
collected from the ectocervix and endocervical canal using an appropriate
collection device.
Bimanual Exam: Uterus is normal in size, shape, and position, and is non-
tender. Adnexa are non-tender and without masses.
Labs/Diagnostics: Pap smear specimen and HPV test sent to the lab for
evaluation.
A: Assessment
PAP results pending
Routine screening: Encounter for screening for malignant neoplasm of cervix
(ICD-10 code: Z12.4).
Patient Status: A low-risk patient given age, history of normal Pap results,
and lack of significant risk factors. The decision to perform the Pap smear is
appropriate per current guidelines.
P: Plan
Continue current medications as ordered. No changed in medications.
Diagnostics:
Pap smear and HPV specimens sent to the lab for cytology and HPV analysis.
Patient Education:
Reassured patient that results are expected within 1-2 weeks.
Educated patient on the importance of regular screening and advised
awareness of any unusual symptoms.
Discussed safe sexual practices and home breast self exams.
Follow-up:
Instructed patient to follow up with the clinic regarding test results.
Discussed the timeframe for the next annual gynecological exam.
Patient can call with any concerns prior to the next scheduled appointment.
The most commonly used E/M codes for OB GYN include:
99202-99205: New patient office visit codes
99211-99215: Established patient office visit codes
It's important to note that the medical decision-making for
E/M codes is based on the following elements:
The number and complexity of problems addressed
The amount and complexity of data reviewed
The risk of complications, morbidity, and mortality
associated with the patient's condition
Proper documentation of the E/M visit is also critical, and
should include the following components:
Chief complaint
History of present illness
Review of systems
Past medical, family, and social history
Physical examination
Medical decision-making
By accurately selecting and documenting E/M codes, OB
GYN providers can ensure that they are properly
reimbursed for their services and comply
with coding regulations.
These codes apply to Preventative/Annual visits
ICD
,Z01.419 if everything was normal and Z01.411 if there
were abnormal findings.
CPT codes for Preventative/ Annual visits:
18-39 years new pt. 99385 and if an est. pt. 99395
40=64 new patient 99386 and est, 99396
65 years or > 993987 if new patient, and est, 99397
> 65 years99387, new patient and est. 99396
These are some billing and coding resources that may be
helpful. Please remember that preventative visits/annuals
are coded differently than routine follow up visits.
Billing and coding resources in CON, student resources.
Tip Sheet: Evaluation & Management Services.
Coding for Evaluation and Management: Answers to
Common Questions.
Outpatient E/M Coding Simplified
PAP SMEAR
,Chief Complaint (CC): Routine Pap smear.
History of Present Illness (HPI): A 54 year old female seen in the office today
for routine screening for PAP smear with HPV testing. MJ is alert and oriented,
dressed appropriately for the weather, well-groomed. Denies fever, fatigue,
pain, or weight gain or loss.
Reason for visit: Annual gynecological examination and cervical cancer
screening.
Last Pap smear: 12/2022 with normal results reported.
Symptoms: Patient denies abnormal vaginal bleeding, discharge, itching,
pelvic pain, or other symptoms.
Menstrual History: Last menstrual period (LMP): 9/2017. Cycle was typically
30, lasting 7 days, and regular.
Obstetric/Gynecological History: Gravida 4, Para 2. Last birth was
05/06/1995. No history of abnormal Pap smears, HPV, or other sexually
transmitted infections (STIs).
Sexual History: Patient is sexually active. Same partner for 38 years.
Past Medical History (PMH): Hysterectomy in 2018, HTN, Hyperlipidemia
Family History (FH): No History of breast or cervical cancer in the family.
Social History (SH): No Tobacco use, occasional alcohol use.
Medications/Allergies: Atorvastatin 40mg daily, Lisinopril 40mg daily
NKA
O: Objective
Vital Signs: BP 141/84 mmHg, HR 69 bpm, RR 16 breaths/min, Temp 98.1.
General Appearance: Patient is well-nourished, alert, and appears in no acute
distress.
Physical Examination:
Abdominal Exam: Soft, non-tender, no palpable masses or organomegaly.
Pelvic Exam:
External: Normal female external genitalia without lesions, erythema, or
discharge.
, Speculum Exam: Vaginal walls moist and healthy. Cervix appears smooth,
pink, and without visible lesions or irregularities.
Pap smear collection: Specimen for liquid-based cytology and HPV testing
collected from the ectocervix and endocervical canal using an appropriate
collection device.
Bimanual Exam: Uterus is normal in size, shape, and position, and is non-
tender. Adnexa are non-tender and without masses.
Labs/Diagnostics: Pap smear specimen and HPV test sent to the lab for
evaluation.
A: Assessment
PAP results pending
Routine screening: Encounter for screening for malignant neoplasm of cervix
(ICD-10 code: Z12.4).
Patient Status: A low-risk patient given age, history of normal Pap results,
and lack of significant risk factors. The decision to perform the Pap smear is
appropriate per current guidelines.
P: Plan
Continue current medications as ordered. No changed in medications.
Diagnostics:
Pap smear and HPV specimens sent to the lab for cytology and HPV analysis.
Patient Education:
Reassured patient that results are expected within 1-2 weeks.
Educated patient on the importance of regular screening and advised
awareness of any unusual symptoms.
Discussed safe sexual practices and home breast self exams.
Follow-up:
Instructed patient to follow up with the clinic regarding test results.
Discussed the timeframe for the next annual gynecological exam.
Patient can call with any concerns prior to the next scheduled appointment.
