Ob-Gyn Coding Alert

If you sailed through "Clean Up Ob Confirmatory Visit Claims With 3 Q&As," then try this more advanced question.

Question 4: Your practice scheduled an initial ob appointment for a pregnant patient (who confirmed her pregnancy at home), but she can't wait to have some of her questions answered. She wants to come in earlier for counseling. The ob-gyn would perform no initial visit or ob panel blood work during this visit. When should you start the ob record?

"This is a tough one," says Pat Larabee, CPC, CCP-P, coding specialist at InterMed in South Portland, Maine.

Answer 4: This scenario could go either way.

Normally, carriers consider all counseling related to a pregnancy included in the global ob service -- whether the physician sees the patient or not. If the ob-gyn counsels the patient regarding normal pregnancy by the nurse or nonphysician, you should wrap this visit into the global care of the patient.

Some payers allow separate reporting, but then you will run into other potential problems. One problem is the nonphysician trying to bill a new patient service before the physician sees the patient.

If you do try to report this separately, you-d report an E/M code such as 99201-99205 for a new patient (if a nurse practitioner or certified nurse midwife is billing directly), based on the time spent on counseling. The provider must document the duration of the counseling visit and might ask, "Does the patient intend to keep her pregnancy? Are there extenuating circumstances about high-risk situations, such as drug abuse, need for genetic counseling, or current high-risk medications?"

If the patient is established, you-d report an established patient E/M visit (99211-99215). If a nurse who was not a certified nurse midwife or a nurse practitioner saw the patient, you must use 99211 for the encounter.

For a diagnosis code, you might try V65.40 (Counseling NOS) or V65.49 (Other specified counseling), but carriers don't usually allow you to use these codes as the primary diagnosis. Also, under ICD-9-CM rules, you would need to use V22.0-V22.1 (Supervision of normal pregnancy ...) as the primary diagnosis because you are providing a service directly related to the pregnancy.

Also, if the provider discusses genetics with the patient, you can instead use V26.3x (Genetic counseling and testing).