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Ob-Gyn Coding Alert

Obstetrics:
Tubal Ligation Claims: Here’s Why Some Payers May Still Balk at +58661
Is a tubal ligation bundled with a cesarean section? Find out. Have a tubal ligation clai... Read more
Gynecology:
Adhesiolysis Myths Debunked: You Can Sometimes Report it Separately
Here are the words your ob-gyn's documentation needs to contain. Time and time again, ob... Read more
News You Can Use:
Get Ready for Pertinent MPFS 2025 Updates
See how telehealth has evolved. The Centers for Medicare & Medicaid Services (CMS) ha... Read more
You Be the Coder:
Diagnosing the Reason for the Cesarean Section
Question: My question is on this case shown below regarding the diagnosis of the bab... Read more
Reader Questions:
Gather More Detail for Documented Mastitis
Question: My ob-gyn documented “left mastitis,” and someone told me that this is... Read more
Reader Questions:
Understand the Rules Around Free Samples
Question: In the past, ob-gyns in our practice have frequently supplied free samples ... Read more
Reader Questions:
How to Code Breastfeeding Counseling
Question: A patient who had problems breastfeeding their newborn came to see our ob-g... Read more
ICD-10-CM Update:
2025 Changes Focused on Notes Beneath Gestational Diabetes Diagnoses
Remember to include additional code for drug patient is taking. The ICD-10-CM code set up... Read more
Gynecology:
Key for Labiaplasty Claims: Why Did the Ob-gyn Perform the Surgery?
Choosing 15839 when your documentation supports it could boost your practice's bottom line... Read more
Modifiers:
Easily Navigate Modifier Conundrums With These Expert Solutions
Modifier 25 is one of the most commonly rejected modifiers. Chances are you probably enco... Read more
Reader Questions:
Try Your Hand at Toxoplasmosis Screening Code
Question: I was wondering if someone could help. We have a newly pregnant patient who... Read more
Reader Questions:
Abide by State Regulations for Minors
Question: We have a 17-year-old patient who has requested that we not discuss their c... Read more
Reader Questions:
What to Do When CNM Bills Global and OB Performs a Repair
Question: This is a completely new situation for me: I have a certified nurse midwife... Read more
Reader Questions:
Understand Medical Identity Theft
Question: Is medical identity theft a type of fraudulent claim? Ohio Subscriber Ans... Read more
Reader Questions:
For Follicle Check, Report This Code
Question: The patient sees primary OB to check on their follicles, as they are trying... Read more
Reader Questions:
Compare and Contrast Modifiers 52, 53
Question: What guidelines should I adhere to for a surgery cancelled midway because o... Read more
Reader Questions:
Native Tissue Does Not Mean Prosthetic Graft/Mesh
Question: Our urogynecologist performed an Altis sling for urinary stress incontinenc... Read more
Reader Questions:
Only Reviewed Ultrasound? Find Out if You Can Use Mod 26
Question: Patient had 76815 (Ultrasound, pregnant uterus, real time with image docume... Read more
You Be the Coder:
Report Radical Hysterectomy?
Question: Would CPT® 58548 be appropriate for this case or 58571 and 38572? PREOPER... Read more
Gynecology:
Part 3: How to Spot Poor Hysterectomy Documentation
Relying on the title of your hysterectomy report could spell disaster. Last month, you le... Read more
Obstetrics:
Do You Know How to Report Pregnant Patient Annual Exams?
Take this three-scenario challenge to test your skills. To ethically maximize your ob-gy... Read more
Reimbursement:
Fight for Your Right to Appeal – and Win
Insurance companies aren't advocating for your office; that's your job. During her HEALT... Read more
Reader Questions:
Forgo Unlisted Code for Lysis of Adhesions
Question: My ob-gyn documented the following procedure: Intraperitoneal placement wa... Read more
Reader Questions:
Know Which Guideline to Follow for SDoH Advice
Question: Should I be reporting every social determinant of health (SDoH) that applie... Read more
Reader Questions:
Study These Behavior Change Service Codes
Question: We have an inpatient addicted to meth and other drugs. The ob-gyn documente... Read more
Reader Questions:
Debulking Services Means MD is Removing Tumors
Question: A patient with recurrent ovarian cancer with previous TAH/ BSO undergoes ne... Read more
You Be the Coder:
Use These Codes for High-Risk Meds During Pregnancy
Question: I need help locating the ICD-10 codes for use of high-risk medication durin... Read more
Gynecology:
Part 2: How to Make Sense of Your Hysterectomy Combo Claims
In a case of two potential coding options, you should factor in RVUs. Remember how you fa... Read more
Obstetrics:
How to Report Complication Visits Outside Global Package
In a case of two potential coding options, you should factor in RVUs. Remember how you f... Read more
Practice Management:
AI May Be Very Useful in Your Practice, Especially During Staffing Shortages
AI must have complete picture of a patient's record to identify billing errors accurately... Read more
Reader Questions:
This Measurement Determines Your Lesion Code
Question: I need some assistance with the following op note. Diagnosis: Vulvar Condy... Read more
Reader Questions:
Can a Nurse Request a Consult?
Question: I have a provider who documented a consultation note for a patient whom a n... Read more
Reader Questions:
Always Remain HIPAA Compliant
Question: One of the physicians in my practice demands we use a sign-in sheet — he ... Read more
Reader Questions:
Do You Know What to Report for Osteopenia?
Question: What is the correct ICD-10 for osteopenia in the hips and spine? South Car... Read more
Reader Questions:
Define MUEs for Clarity
Question: Could you please clarify what “MUE” means and explain how it impacts my... Read more
You Be the Coder:
Hysterosalpingogram or Hysterosonogram
Question: What is the difference between a hysterosalpingogram and a hysterosonogram?... Read more
Gynecology:
Part 1: Highlighting 4 Factors to Pinpoint Which Hysterectomy Code to Use
Warning: You should not count fibroid weight with the weight of the uterus. Approximatel... Read more
Obstetrics:
Starting the Global Record too Soon? You May Miss Out on $111
Test yourself with these 3 questions. A patient has taken a pregnancy test at home and yo... Read more
Practice Management:
Stop Denials in Their Tracks With These Handy Tips
Make sure team members communicate clearly with one another. Denials can be a major thre... Read more
Reader Questions:
When MD Leaves, Do This for Pregnant Patients
Question: One of our providers recently left our office, so all the patients were tra... Read more
Reader Questions:
Think Twice Before Reporting 99000
Question: We have a lot of patients who self-swab for sexually transmitted infection ... Read more
Reader Questions:
Beware Addition of Urinalysis Code to E/M
Question: For all lab tests performed in the office, our nurse researches the histor... Read more
Reader Questions:
Consider Your ICD-10 Options for Rubella Non-Immune Status
Question: How do you code Rubella non-immune status in a pregnant patient? I can only... Read more
Reader Questions:
Report FBR by How Ob-Gyn Got It Out
Question: My physician removed a foreign body from the vagina of a 4-year-old using a... Read more
You Be the Coder:
Be Wary of the Term “Cystectomy”
Question: I am new to this, and I am hoping someone can give me any input. Physician... Read more
Gynecology:
Do You Know Whether the LEEP Was a Conization or Biopsy? Follow 3 Steps
Solve potential problems by asking, “Did the ob-gyn remove part of the endocervix?” L... Read more
Coding Quiz:
Test Yourself: Pregnant Patient Annual Exams
Be cautious about what you use for your primary diagnosis. To ethically maximize your ob... Read more
Unlisted Procedures:
Here’s How to Ease Your Unlisted Procedure Coding Process
Key: Reports should use simple, straightforward language. If you've ever filed an ob-gy... Read more
Reader Questions:
Here’s Your Scoop on the 60-Day Overpayment Rule
Question: We've heard that Centers for Medicare & Medicaid Services (CMS) says we... Read more
Reader Questions:
You Need Proof for Modifier 82
Question: Is there a difference in the reimbursement of procedures for modifiers 80 (... Read more
Reader Questions:
Code This Ureterolysis Example
Question: I need help with this ureterolysis note. Our gynecology oncologist is doing... Read more
Reader Questions:
For High-Risk Medications During Pregnancy, Use These Codes
Question: I need help locating the ICD-10 codes for use of high-risk medication durin... Read more
You Be the Coder:
Determine Your Dx After Cancer Surgery
Question: When can we bill a visit after a surgery for cancer? My colleague says that... Read more
Obstetrics:
Double Trouble: How to Code NSTs and BPPs for Twin Pregnancies
Learn different options to capture the extra work. When a patient who is carrying twins ... Read more
Case Study:
Navigate This Urogynecology Crossover Procedure
Avoid confusion by focusing on the code descriptors. Navigating the specialty of urogyn... Read more
Myth Busters:
Fibroid Coding Got You Frustrated? 5 Myth Busters Fix Your Claims
Find out what your fibroid diagnosis options are. If you're reporting uterine fibroid rem... Read more
Reader Questions:
Count Oocytes for 89280-89281
Question: Codes 89280 and 89281 don't have a National Correct Coding Initiative (NCCI... Read more
Reader Questions:
Include Hymenectomy As Part of Surgery
Question: One of our providers performed a hysteroscopy dilation and curettage for re... Read more
Reader Questions:
Repeat Pap Plus Urinary Tract Infection
Question: A Medicare patient who is high risk due to sexual behavior came in for her ... Read more
You Be the Coder:
Prophylactical Placement of Ureteral Stents
Question: If the ob-gyn places catheters for identification of the ureters (52005) d... Read more
Gynecology:
+99459: 5 FAQs Clarify How to Use This Expense Only Code
Here's what your physician's documentation needs to include. Since January 1, you can use... Read more
Obstetrics:
Billing Infertility Claims? Focusing on These Types of Codes Can Help
You may want to hold off reporting N97.9. According to the Centers for Disease Control ... Read more
NCCI:
Follow Expert Advice to Conquer Challenges With NCCI Edits
Don't abuse modifier 59. Although most coding software programs incorporate the quarterly... Read more
Reader Questions:
Possible Molar Pregnancy
Question: My ob-gyn treated a patient they suspected had a possible molar pregnancy b... Read more
Reader Questions:
Does Repeat Pap Smear Warrant Well Woman Code? Find Out
Question: Our ob-gyn recently performed a repeat Pap smear for a woman as her Pap sme... Read more
Reader Questions:
You Need More Documentation for Mastitis
Question: My ob-gyn documented “left mastitis,” and someone told me that this is... Read more
You Be the Coder:
Fetal Doppler Echocardiographies
Question: Fetal cardiac evaluation was performed using 2D ultrasound, color Doppler, ... Read more
Gynecology:
2 Tips Clarify How to Code Ovarian Cysts
Bonus: Here's the documentation you need for cyst removals. Are you scratching your head ... Read more
Obstetrics:
Why You Need to Look For “Polyhydramnios” In Your Amnio Claim
Find out if you can report the ultrasound guidance separately. Do you know what to do i... Read more
E/M Coding:
Follow 5 Tips to Solidify Your Inpatient Care Coding
Stay on top of the hospital E/M revisions. For the last year, you have been using a revi... Read more
Reader Questions:
Clarify HIPAA Terminology
Question: What is the difference between “consent” and “authorization” in th... Read more
Reader Questions:
Ask if This Procedure Was for a Bartholin’s Cyst
Question: My ob-gyn listed the procedure as perirectal cystectomy and pre-op diagnosi... Read more
Reader Questions:
You Need More Documentation for Mastitis
Question: My ob-gyn documented “left mastitis,” and someone told me that this isn... Read more
Reader Questions:
Are Inductions Part of Global to Deliveries? Find Out
Question: If a patient is in the hospital for several days being induced for a delive... Read more
You Be the Coder:
Control of Bleeding Case
Question: Could you help me code this control of bleeding case? Doctor states: “33... Read more
Gynecology:
Do You Know How to Report What Ob-Gyn Did in Addition to Colposcope?
Tip: The difference between a biopsy and LEEP biopsy is the instrument used. Your colpos... Read more
Obstetrics:
Untangle Your Trickiest Twin Delivery Claims
Babies born on different calendar dates? Here's what to do. How should you report a twin ... Read more
Modifiers:
3 FAQs Will Guide You Away From Making Modifier 22 Mistakes
Find out how much longer a procedure should take. Appending modifier 22 (Increased proce... Read more
CPT® 2024 Update:
Federal Register Clarifies Pelvic Exam Add-on Code
Here's why there's no guarantee your practice will be paid. CPT® 2024 includes a new add... Read more
Reader Question:
Order Your Surveillance Diagnosis Codes Like This
Question: A patient is 2+ years since completion of treatment for endometrial ca... Read more
Reader Question:
Assign Codes — and Responsibility for Code Choices
Question: Who is responsible for the final diagnosis used for an office/ outpatient e... Read more
Reader Question:
Take Advantage of Opportunities to Educate Providers
Question: Our provider tends to use the terms “epigastric pain” and “heartburn�... Read more
You Be the Coder:
Free Samples Means Following These Rules
Question: In the past, ob-gyns in our practice have frequently supplied free samples ... Read more
Ob-Gyn Coding:
Here’s What to Ask Your Payers About IUD Coding
Understand why some payers won't pay for removals. Many coders confess they're tearing th... Read more
Ob-Gyn Coding:
Learn What to Do When Induction Takes Days
Question: Do most insurances cover evaluation and management (E/M) codes for patients... Read more
Ob-Gyn Coding:
Solve This Separation of Labia Scenario
Question: I'm looking for some assistance on the below procedure note. I'm leaning to... Read more
Ob-Gyn Coding:
Use These Codes for High-Risk Meds During Pregnancy
Question: I need help locating the ICD-10-CM codes for use of high-risk medication du... Read more
Ob-Gyn Coding:
Understand What to Do When a Second Provider Delivers the Placenta
Question: I have a provider who was present for a vaginal vacuum-assisted delivery, a... Read more
Ob-Gyn Coding:
Learn the New Ob-Gyn Codes, Deletions, and Guideline Updates by Jan. 1
Removal of endometria guideline's rationale remains to be seen. With January 1 comes a va... Read more
Ob-Gyn Coding:
When You Should Start the Ob Record
Question: My ob-gyn saw a patient who knows that she's pregnant via a positive home pregna... Read more
Ob-Gyn Coding:
Learn How to Report Simple Skinning Vulvectomy
Question: I have a procedure that has me wondering if it meets the requirement for a ... Read more
Ob-Gyn Coding:
Adopt These Subtle but Extensive E/M Changes Before January 1 Hits
Say goodbye to 99441 through 99443 next year. When CPT® 2025 becomes effective on J... Read more
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