Ob-Gyn Coding Alert

Here are the ICD-10 codes you should be using.

The starting line for global maternal care isn’t always clear-cut when a patient presents for an annual visit.

She may or may not know if she’s pregnant, but you should stick to one rule — you must code what you know at the end of the visit if it is more specific than what was known at the beginning.

Attack This Annual-Exam Scenario

Annual visits often lead to confusion when your ob-gyn establishes a patient’s pregnancy. You should choose from a range of different E/M codes according to three scenarios:

• a patient's annual visit leads to a diagnosis of her pregnancy
• she arrives knowing that she is pregnant
• the ob-gyn eliminates other possible diagnoses.

Scenario 1: Your ob-gyn diagnoses pregnancy during a patient’s annual exam. Can you still report the annual exam?

Solution 1: Yes, you can still report the annual exam. You need only link the pregnancy test result diagnosis to the diagnostic test. Your claim should look like this:

• the annual exam (99384-99386 for new patients or 99394-99396 for established patients) linked to either Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) or Z01.419 (... without abnormal findings).
• the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods) linked to Z32.01 (Encounter for pregnancy test, result positive).

Don’t miss: Reporting the routine pregnancy codes Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.03 (... third trimester), Z34.80 (Encounter for supervision of other normal pregnancy, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), or Z34.83 (... third trimester) — or even Z33.1 (Pregnancy state, incidental) — is optional. Bottom line: The ob-gyn is not monitoring the pregnancy at this visit, and you have documented what you know at the end of the visit by using Z32.01 (Encounter for pregnancy test, result positive).

As for the ob record, you should not begin it until the next visit. Otherwise, carriers will consider the whole visit part of the global ob service.

Think of it this way: Tell your doctors to not start the ob flow sheet until after the first visit where the doctor confirmed the patient’s pregnancy, experts advise. The next visit he schedules after the confirmation is the start of the ob flow sheet. This will prevent visits where patients come in to start prenatal care, only to find out they are not pregnant.

Keep in mind: 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 and include the appropriate pregnancy diagnosis. If you have a positive pregnancy test, that code will be Z32.01.

What to Do When Patient Knows She’s Pregnant

Scenario 2: The patient comes in for her annual examination, already knowing she is pregnant. Can you still report the patient’s annual exam?

Solution 2: Yes, you should code the visit as an annual exam as that is what the patient was coming in for. Additionally, code for the diagnostic test to confirm the pregnancy. Remember that in order to bill a problem E/M service at the time of the preventive, there must be a separate significant E/M service documented. Simply confirming the pregnancy test result may not meet the criteria or a separate E/M but certainly would support the diagnostic test.

Remember to link the pregnancy diagnosis to the test, not the annual examination. Your claim should look like this:

• the annual exam code linked to either Z01.411 or Z01.419
• the diagnostic test (such as 81025) linked to the pregnancy exam diagnosis (Z32.01)
• a low-level service, if documented (for example, 99212, Office or other outpatient visit, established patient, problem-focused history and examination, straightforward medical decision-making) with modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) added and linked to Z34.-- or Z32.01.

As for the global ob package, the patient should schedule a full visit with the ob-gyn. All visits, including the initial encounter with the physician, count toward the total for global care, which generally includes 13 outpatient antepartum visits. Getting an ultrasound paid by any insurance company at the time the patient presents for an annual isn’t easy. Save yourself some hassle and set up a separate appointment for the ob-gyn to initiate the prenatal care, experts recommend.

Attempt This No-Complaint Scenario

Scenario 3: The patient presents for her annual exam but has other complaints. The ob-gyn discovers the pregnancy. Can you still report the patient’s annual exam?

Solution 3: Yes. Actually, the work involved in eliminating other possible diagnoses may constitute a higher-level E/M service. That work would not focus on or relate to the pregnancy, except to confirm it with a test. Your claim should look like this:

• the annual exam code linked to either Z01.411 or Z01.419
• the higher-level E/M service (such as 99214, Office or other outpatient visit for an established patient ... 25 minutes face-to-face) with modifier 25 added and linked to the diagnosis for the problems evaluated
• the diagnostic test (such as 81025) linked to Z32.01.