Ob-Gyn Coding Alert

Don't forget to document higher-level codes.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 Des Plaines, Ill.For example: If you report 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 complexity), you must [...]