A 32-year-old married female presents to her OB/GYN office for diaphragm fitting. After performing a pelvic examination and routine physical, the OB measures the cervix and adjusts the diaphragm so that it fits neatly over the cervical opening. The OB then instructs the patient in how to place the diaphragm for most effective birth control, as well as how to remove, clean, and store the diaphragm. Satisfied that the patient understands how to use the device properly, she allows the patient to leave the office with a follow-up appointment scheduled in one month. How should the OB/GYN code for this visit?

Question

Quizplus · Accepted Answer

The OB/GYN should code for this visit with 99395 (Routine Physical and Pelvic Examination). OB/GYNs are considered primary care physicians who can perform routine physical examinations. Code 57170 (Diaphragm or Cervical Cap Fitting with Instructions) also needs to be included on the claim because the OB performed an additional service. Furthermore, it is necessary to combine the modifier -59 with code 57170 to indicate that there was a distinct procedural service provided to the patient on the same day as an E/M service, which in this case, is a routine physical and pelvic exam.

A 32-Year-Old Married Female Presents to Her OB/GYN Office for Diaphragm