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Ob-Gyn Coding Alert

Coding Quiz:

2 Ob-Gyn Scenarios Evaluate Your E/M Coding Skills

Published on Sun Jul 25, 2010

Learn why 'review of systems unremarkable' doesn't make the grade.To avoid incorrectly reporting higher-level new patient visits, you should only pick your E/M code based on the lowest level of any of the three components your ob-gyn documents: history, exam, and medical decision-making.Learn What a Higher-Level Code IncludesYou can use a higher-level E/M code if you meet the requirements with solid documentation detailing history, exam, and medical decision-making.Avoid this pitfall: "What I see in performing audits is the lack of information in the history requirements - specifically review of systems (ROS), and past, family, and social history (PFSH)," says Lynn Anderanin, CPC, CPC-I, COSC, senior coding consultant for Health Info Services in Park Ridge, Ill.For example: If you use 99203 (Office or other outpatient visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low [...]
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