Would a well-woman visit with a Pap smear, follow-up on ankylosing spondylitis, and discovery of a breast implant rupture requiring a plastic surgery referral still be coded as 99396?

CPT Coding for Well-Woman Visit with Additional Findings

This encounter should NOT be coded as 99396 alone because significant additional evaluation and management work was performed beyond the preventive medicine service. When a well-woman visit includes substantial problem-oriented evaluation of existing conditions (ankylosing spondylitis follow-up) and new findings requiring referral (breast implant rupture), you must append an appropriate problem-oriented E/M code (99212-99215) with modifier -25 to the preventive medicine code.

Coding Algorithm for Mixed Preventive and Problem-Oriented Visits

Primary Code Selection:

• The 99396 (preventive medicine, established patient, age 40-64) remains appropriate for the well-woman examination and Pap smear component of the visit
• However, this code alone does not capture the additional work performed

Additional Code Requirements:

• Add a problem-oriented E/M code (99212-99215) with modifier -25 when significant, separately identifiable evaluation and management services are provided beyond the preventive service
• The level selected (99212-99215) should reflect the medical decision-making complexity of addressing the ankylosing spondylitis follow-up and newly discovered breast implant rupture

Key Documentation Requirements

To support both codes, documentation must clearly show:

• The preventive medicine service was performed (well-woman exam, Pap smear, age-appropriate counseling)
• Separate documentation of the problem-oriented evaluation, including:
  • Assessment of ankylosing spondylitis status and management
  • Evaluation of the breast implant rupture finding
  • Medical decision-making regarding the plastic surgery referral
  • Any imaging orders or additional workup initiated

Common Pitfall to Avoid:

• Do not code only 99396 when substantial problem-oriented work is documented—this undervalues the physician's work and may constitute undercoding
• The modifier -25 is essential to indicate the problem-oriented E/M service was "significant, separately identifiable" from the preventive service

Clinical Context for the Breast Implant Finding

Regarding the breast implant rupture discovery:

• Clinical examination alone is unreliable for detecting implant rupture and should not be the sole diagnostic method 1, 2
• The American College of Radiology recommends MRI without contrast as the primary diagnostic test for symptomatic patients with silicone implants, with sensitivity of 87% and specificity of 89.9% 1
• Ultrasound can achieve 94.7% diagnostic accuracy when performed by experts and may be ordered first to rapidly assess for urgent complications 2
• Plastic surgery referral within 2-4 weeks is appropriate for suspected implant complications 2

This additional evaluation and referral coordination represents significant work beyond the preventive service and justifies the additional E/M code with modifier -25.