Ob-Gyn Coding Alert

Heads up: Pregnancy won't always be your primary diagnosis

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.

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, says Rachel Morales, CPC, coding specialist at FMC Management in Amarillo, Texas. 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 V72.31 (Routine gynecological examination)

- the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods) linked to V72.42 (Pregnancy examination or test, positive result).

Don't miss: Reporting the routine pregnancy codes V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy), or even V22.2 (Pregnant 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 V72.42, says Sarah Chapman, administrative assistant/medical coder for Etowah Valley Ob/Gyn in Cartersville, Ga.

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: -We-ve told our doctors to not start the ob flow sheet until after the first visit where the doctor confirmed the patient's pregnancy. The next visit he schedules after the confirmation is the start of the ob flow sheet,- Morales says. -This prevents visits where patients come in to start prenatal care, only to find out they are not pregnant,- Chapman adds.

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 V72.42.

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 a low-level service and a diagnostic test to confirm the pregnancy. -The annual visit is what the patient was coming in for,- says Kimberly Horn, CPC, insurance coordinator for Village Coding in Village, Okla.

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

- the low-level service (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 on the same day of the procedure or other service) added and linked to V22.0-V22.2.

- the diagnostic test (such as 81025) linked to the pregnancy exam diagnosis (V72.42)

- the annual exam code linked to V72.31 (Routine gynecological examination).

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,- Chapman says.

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 ineliminating other possible diagnoses may constitute a higher-level E/M service, Horn says. 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 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 V72.42

- the annual exam code linked to V72.31.