Revenue Cycle Insider

Question: My ob-gyn saw a patient who knows that she’s pregnant via a positive home pregnancy test and simply “confirms the confirmation.” I’m confused. Should I start the ob record now or later?

California Subscriber

Answer: You should start the ob record at the next visit.

If the ob-gyn performed only the urine pregnancy test, you’d report 81025 (Urine pregnancy test, by visual color comparison methods) or possibly a low-level evaluation and management (E/M) service (such as 99202 [Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.] for new patients or 99211 [Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional] or 99212 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.] for established patients) if some discussion about her health took place.

You will use Z32.01 (Encounter for pregnancy test, result positive) when your ob-gyn simply tests to see if the patient is pregnant. Because you’ll be coding for what you know at the end of the visit if it is more specific than her presenting reason, this diagnosis code will go on both the E/M code and the urine test.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor