E/M Might be the Answer to BCP for Acne

Birth control pills for acne can be a perplexing coding problem. Occasionally, we come across a case in which a patient obtains birth control pills because her dermatologist recommended them to help clear up an acne problem. Some people say that we should not even code the birth control pills (oral contraception), but if this is the only problem that the patient presented to the OB-GYN for, does that mean that we should still not code for it to keep with specificity? E/M might be the answer to this particular problem you may come across.

If an OB-GYN prescribes birth control pills (BCPs) to a patient for acne problems, that is what you code as a diagnosis (706.1, Other acne; acne: NOS, conglobata, cystic, pustular, vulgaris, blackhead, comedo). The patient is not visiting the OB-GYN to obtain oral hormonal contraception as a means to prevent a pregnancy, so this is not the primary diagnosis.

If you want to list birth control as a secondary diagnosis, then that is your choice. You will report an E/M service for this encounter using a problem E/M code (99201-99215) because the visit is to deal with a problem that the patient has (an acne problem), rather than for a preventive service (birth control pills as a means to prevent a pregnancy). Check with your OB-GYN’s documentation for history, exam, and medical decision making in order to choose the correct level of E/M code for this particular patient’s visit.

View all Articles by: Melissa Clark, CCS-P