What are the review of system requirements when an annual physical (99381-99387, 99391-99397) is performed/billed by an OBGYN practitioner?
These codes were revised in 2002, and CPT® stated that comprehensive as defined in the Documentation Guidelines doesn’t apply to comprehensive in these codes. In fact, the Documentation Guidelines never mention preventive services.
The CPT® Assistant in May, 2002 noted
“The descriptors of the preventive medicine codes 99381-99397 were also revised to clarify that the preventive medicine services represent comprehensive (age and gender appropriate) history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and ordering of appropriate immunization(s) and laboratory/diagnostic procedures for recommended physician intervention standards, which are set and published by preventive medicine agencies.
Note that the language “ordering of appropriate immunization(s)” was added to the code descriptor to specify that the ordering of immunization(s) is an inclusive component of the preventive medicine service. However, as noted in the guidelines preceding the preventive medicine services codes, the actual provision of immunizations should be reported separately. Therefore, the immunization administration codes 90471-90474 and the vaccine product codes 90476-90748 should be additionally reported, when performed.”
As, I interpret this, CPT® is not mandating any specific number of systems be reviewed in the ROS. The age and gender of the patient will determine the detail documented in the history. Clearly, the GU system would be documented for a well woman exam.
CPT® specifically refers to resources published by “preventive medicine agencies.” The American College of Obstetrics and Gynecology (ACOG) developed a website with recommendations for women’s preventive services. Their description of a well woman visit is not prescriptive for a complete ROS. They have developed a clinical chart with suggested screening by age, available on their website, www.womenspreventivehealth.org
What about the 2021 changes? Does this change?
In January, 2021 the requirements for codes 99202–99215 change, significantly. Neither history nor exam are used to select the level of E/M service for these codes. CPT hasn’t changed its language however. It says:
“The “comprehensive” nature of the preventive medicine services codes 99381-99397 reflects an age- and gender- appropriate history/exam and is not synonymous with the “comprehensive” examination required in evaluation and management codes 99202-99350.” CPT 2022 Professional ed. page 48.
Relevant Search Terms: ROS, ob/gyn exam, annual physical, preventive services, review of systems