Ob-Gyn Coding Alert

Editors Note: This months case comes from a compilation of many questions that Ob-Gyn Coding Alert has received regarding correct coding for ob patients who require more care than that which is included in the global ob billing.

Angela, a hypothetical new 25-year-old patient, presents with a complaint of being late for her period. The usual pregnancy test is performed, and she is diagnosed as 8 weeks pregnant with the physician noting gravid 1, para 0. She is scheduled to be seen monthly until 28 weeks gestation and biweekly until 32 weeks gestation. At 10 weeks, because of light spotting she presents for a visit other than her monthly visit. At 21 weeks, she presents again for an extra visit and is diagnosed and treated for a urinary tract infection (UTI).

When Angela presents for her 32-week visit, she is found to have developed mild hypertension. To ward off preeclampsia, the ob/gyn prescribes bed rest, and Angela is managed expectantly with weekly visits through 39 weeks gestation. Four days after her last visit, she vaginally delivers a healthy seven-pound boy. The postpartum course is uneventful, and she is discharged after her six-week visit.

The question is: how do you correctly code for maximum reimbursement for the ob patient who has extra visits and mild complications during her antepartum care?

Terminology and Procedure

1. Terminology. While the terminology of basic obstetrics is well-understood by most ob-gyn coders, we will review several items:

Gravid 1, para 0 is the medical terminology that provides a ratio of the number of pregnancies a woman has had to the number of viable-size deliveries. The gravid number refers to all of pregnancies a woman has had regardless of how long she carried the fetus or whether or not she miscarried or aborted. Para refers to the number of deliveries of viable size (over 500 grams) a woman has had.

Hypertension during the course of a pregnancy is sometimes referred to as pregnancy-induced hypertension (PIH). ACOGs committee on terminology has suggested that hypertension should be defined as a rise of 15 mmHg diastolic and a rise of 30 Hg systolic blood pressure, or a systolic blood pressure value of 140 mmHg over a diastolic blood pressure of 90 mmHg, with blood pressure values obtained on two occasions at least six hours apart.

Preeclampsia is usually diagnosed in the pregnant patient after 20 weeks when there is a presence of hypertension, edema or water retention, and elevated protein in the urine (proteinuria).

2. Procedures/services. There are no unusual procedures in this case, but the coder will want to note which provided services are included in, and which are outside, the normal definition of uncomplicated maternity care and delivery. Normally provided ob services do not include an office visit to establish pregnancy (including a pregnancy test). According to the CPT, the global ob begins after the pregnancy is determined, and includes the initial and subsequent history, physical examination, recording of weight, blood pressure, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, visits every two weeks up to 36 weeks gestation, and weekly visits until delivery. Also included are hospital admission and discharge, delivery, and postpartum office visits. The extra visits for the spotting and UTI are not included.

Coders Notebook

The following tips will assist you in coding both the routine and complicated obstetrical patient.

1. Initial visit. This first visit is not part of the global package because the patient was diagnosed as being pregnant at this visit. If she had come in with a positive pregnancy test, this visit would have been the initial ob visit and part of the package. You will code the first visit using the E/M code 9920X, new patient encounter, linked to a diagnosis of 626.8, suppression of menstruation. Note: you cannot code 626.0, amenorrhea, because in order to use this code the patient must have had no period for three months, and this is only one missed period.

2. Non-antepartum visit. During her 21st week, Angela is seen for a UTI. This visit is outside the global and will be coded using the visit code 9921X, established patient encounter. The diagnosis code you use for this visit depends on whether the UTI is complicating pregnancy. If it is not (and only the physician can make this decision), you will code the visit as 599.0, UTI, and V22.2, pregnancy incidental. If the UTI is complicating the pregnancy, code the diagnosis as 646.63, GU infection in pregnancy.

3. Additional antepartum care. Angela was also seen at 10 weeks for vaginal bleeding, and at 32 weeks for hypertension. The visits will be coded using the E/M code (9921X). The diagnosis code for the 10-week visit depends on clarification from the physician, as light spotting can only be coded as 640.93. This cannot be called a threatened abortion, 640.03, unless the physician confirms this. For the 32-week visit, the diagnosis code will depend on the definition of mild hypertension. The physician will need to specify whether hypertension is a pre-existing condition (642.0X), transient hypertension of pregnancy (642.3X), mild or unspecified preeclampsia (642.4X - requires presence of albuminuria or edema or both), or unspecified hypertension (642.9X). The latter diagnosis may not be accepted by the third party payer.

4. Delivery. Angelas entire ob package will be coded using 59400 for routine obstetric care and vaginal delivery. The diagnosis codes will depend on whether she has the hypertension when she goes in to deliver. If she does not, the diagnosis will be 650, normal delivery + V27.0, single live birth. If the hypertension is present, the diagnosis codes will be 642.X1 + V27.0.

Article contributors: Expert advice for this case study was provided by the following sources: Melanie Witt, RN, CPC, MA, program manager, department of coding and nomenclature, American College of Obstetricians and Gynecologists, Washington, DC; Evelyn M. Gross, CMM,CPC, NR-CMA, Healthcare Specialist, E.M. Gross and Associates, South Amboy, New Jersey; Thomas Kent, CMM, Principal, Kent Medical Management, Dunkirk, MD. Text reference: Dunnihoo DR. Fundamentals of Gynecology and Obstetrics. Philadelphia: J.B. Lippincott and Co.; 1990. If you have a complicated coding situation, please fax a case description to 941/261-6713.