REIMBURSEMENT AND CODING
Preventive coding can be a snap
Billing for the well-woman exam, with Medicare Guide
Melanie Witt, RN, CPC, COBGC, MA
The American College of Obstetricians and Gynecologists (ACOG) has recommended dividing a woman's life cycle into four intervals—ages 13–18, 19–39, 40–64, and older than 65—in order to best organize the approach to primary and preventive health care.1 This paradigm provides a structure for organizing the clinical approach to physical examination, laboratory testing, counseling, and immunizations. In addition, it helps to highlight the diseases and health problems most prevalent among women at each life-stage.
Different professional organizations—US Preventive Services Task Force (USPSTF), American Medical Association, American College of Physicians, ACOG, American Academy of Family Physicians, American Academy of Pediatrics, and Advisory Committee on Immunization Practices—have used varying analytical methods to determine recommended health services by age group; consequently, these organizations have somewhat divergent recommendations. However, the recommendations of most organizations share many similarities. In this comprehensive guide, I point out those similarities. Keep in mind that recommendations change over time, and it is important to use your professional judgment when approaching each patient.
TABLE
Physical examination and laboratory testing services according to a patient's age, based on ACOG recommendations1
| Health service | 13–18 years | 19–39 years | 40–64 years | 65 years and older |
|---|---|---|---|---|
| Physical examination | ||||
| Height | X | X | X | X |
| Weight | X | X | X | X |
| BMI | X | X | X | X |
| Blood pressure | X | X | X | X |
| Tanner staging of secondary sexual characteristics | X | |||
| Neck exam (assess thyroid and presence of adenopathy) | X | X | X | |
| Breast exam | X | X (including axillae) | X (including axillae) | |
| Oral cavity | X | X | ||
| Abdominal exam | X | X | X | X |
| Pelvic exam | If indicated | Age 21 and older | X | X |
| Skin exam | X | X | X | |
| Laboratory testing | ||||
| Chlamydia | If sexually active | If age 25 or younger and sexually active | ||
| Gonorrhea | If sexually active | If age 25 or younger and sexually active | ||
| HIV | If sexually active | X | X | |
| Cervical cytology | Age 21-29: Every 2 years Age 30 and older, low risk: Every 3 years Age 30 and older, high risk (immunosuppressed or HIV infection): Annually | Low risk: Every 3 years High risk (immunosuppressed or HIV infection): Annually | Consider discontinuing in women with:
| |
| Colorectal cancer screening (colonoscopy preferred) | Age 50 and older, low risk: Every 10 years High risk: Consult colorectal screening guidelines* | Every 10 years | ||
| Fasting glucose | Age 45 and older: Every 5 years | Every 5 years | ||
| Lipid profile | Age 45 and older: Every 5 years | Every 5 years | ||
| Mammography | Age 40 to 49: Every 1-2 years Age 50 and older: Annually | Annually | ||
| BMD | Not more frequently than every 2 years | |||
| TSH | Every 5 years | |||
| Urinalysis | X | |||
| Abbreviations: BMD, bone mineral density; BMI, body mass index; HIV, human immunodeficiency virus; TSH, thyroid stimulating hormone. *Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. CA Cancer J Clin. 2008;58(3):130–160. | ||||
The adolescent: 13–18 years
Screen. Guide. Immunize. ACOG recommends that the first visit take place between 13 and 15 years of age, with annual visits thereafter. The purpose of the first, and subsequent, visits is to assess health status, including menstrual history and body mass index (BMI), and to provide health guidance, screening, and preventive health services. This initial visit generally does not include a pelvic examination. A physical examination is not required at every visit but is recommended to occur at least once during early, middle, and late adolescence.
Target your screening practices. Screen adolescents for the following conditions during clinical preventive services: hypertension; hyperlipidemia; obesity and eating disorders; physical, sexual, or emotional abuse; learning or school problems; substance use; depression and risk of suicide; sexual assault; sexual behavior that may lead to pregnancy or sexually transmitted disease (STD); and tuberculosis and HIV, unless the patient opts out (TABLE).
Anticipate. Then guide. Using anticipatory guidance, you can help adolescents understand their physical, psychosocial, and sexual development and motivate them to be involved in their health and health-care decisions. Issues relevant to adolescents include dietary habits; injury prevention, through the use of helmets and seatbelts; regular exercise; responsible sexual behaviors; avoidance of substances that can be abused; strategies for dealing with bullying; and avoidance of behaviors that might have negative consequences, such as vandalism, stealing, and sharing personal information with strangers.
Recommended immunizations. For this age group, immunizations, unless previously given, include:
- 1 or 2 doses of measles, mumps, and rubella
- 2 doses of varicella if not previously infected
- a booster dose of tetanus if ≥10 years have elapsed since the last dose
- human papillomavirus (HPV)
- annual influenza.
Other immunizations that may be warranted on the basis of medical condition, occupation, lifestyle, or other indications include: 3 doses of hepatitis B, 2 doses of hepatitis A, 1 or more doses of meningococcal, and 1 or 2 doses of pneumococcal.