Ob-Gyn Coding Alert

Annual visits often lead to confusion when it comes to establishing a patient's pregnancy. Take this three-part challenge by deciding if the ob-gyn package begins based on these scenarios:

• a patient's annual visit leads to a diagnosis of her pregnancy,

• she arrives knowing that she is pregnant, or

• the ob-gyn eliminates other possible diagnoses.

Hint: In the majority of circumstances, you should not begin counting antepartum visits for the global maternity codes (59400, 59510, 59610, 59618) until the next full visit, coding experts say.

Scenario 1: If the ob-gyn diagnoses pregnancy (V72.42, Pregnancy examination or test, positive result) during a patient's annual exam (99384-99386 for new patients, or 99394-99396 for established patients), you can still report the annual examination, as long as you link the pregnancy diagnosis to the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods).

Trap: You should not report codes V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V22.2 (Pregnant state, incidental) because these codes imply your ob-gyn has begun supervising the pregnancy.

Rule: You must report what you know at the end of any visit. If the ob-gyn knows the patient is pregnant, you must report the patient as pregnant. Code V72.42 suffices because the pregnancy care has not begun. You will also report V72.31 (Routine gynecological examination) in support of the annual exam.

Does global ob package start? No. You should not begin the ob record until the next visit. Otherwise, carriers will consider the whole visit part of the global ob service.

Scenario 2: The patient schedules her annual examination but already knows she is pregnant. If the physician is merely confirming this fact, you should code the visit as a low-level service (for example, 99212, Office or other outpatient visit for the evaluation and management of an established patient ... 10 minutes face-to-face...) to confirm her pregnancy (such as 81025). Remember to link the diagnosis (V72.42) to the test.

Does global ob package start? No. "The patient was here for her annual exam, not to start care for her pregnancy," says Angela Maddox, office manager of Pathway Women's Health PLC in Battle Creek, Mich. After this visit, the patient will schedule a full visit with the ob-gyn. "The global care would begin at the next visit," says Patricia Larabee, CPC, CCP-P, coding specialist for InterMed in South Portland, Maine. All visits, including the initial encounter with the physician, count toward the total for global care, which generally includes 13 outpatient antepartum visits.

Scenario 3: If the patient presents for her annual exam but has other complaints, and the ob-gyn then discovers pregnancy, the work involved in eliminating other possible diagnoses may constitute a higher-level E/M service (such as 99214, Office or other outpatient visit for the evaluation and management of an established patient ... 25 minutes face-to-face...).

That work would not focus on or relate to the pregnancy, except to confirm it with a test (like 81025). Therefore, if the ob-gyn is eliminating other diagnoses and incidentally confirms pregnancy, you should not list V22.0-V22.2 as the principle diagnosis. As with the examples above, what you know at the end of the visit is that she is pregnant. That means you must list V72.42. Additionally, you can report symptoms to indicate the initial reason for the visit (such as 626.8, Missed period, or 626.4, Irregular periods).

Does global ob package start? No. The patient would return again to begin her global ob care.

Note: Check back with Ob-Gyn Coding Alert next month to determine when the global ob care begins for nonscheduled visits.