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. At the beginning of the visit, she may or may not know she's pregnant, but you should stick to one rule: you must code what you know at the end of the visit.
Link Test Result to Test in This Annual-Exam Scenario
Annual visits often lead to coding 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. 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 the ob 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.
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.
Patient Knows She's Pregnant? Here's What to Do
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 annual visit 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 Okla.
Remember to link the pregnancy diagnosis to the test, not the annual examination. Your claim should look like this: the diagnostic test (such as 81025) linked to the pregnancy exam diagnosis (V72.42) the annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) linked to V72.31.
Caution:
You would not normally also bill for a lowlevel service (such as 99211) under this circumstance unless there was a significant and separate E/M service related to the pregnancy evaluation at this annual visit. In most cases, the physician will merely confirm the home pregnancy test and schedule the patient for obstetric care at the next visit. But keep in mind that if the pregnancy is being evaluated or managed, the payer is likely to include the entire visit as part of global care.
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. Experts advise you to save yourself some hassle and set up a separate appointment for the ob-gyn to initiate the prenatal care.
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, 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 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) added and linked to the diagnosis for the problems evaluated the diagnostic test (such as 81025) linked to V72.42 the annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) linked to V72.31.
-- ICD-10:
When your diagnosis code system changes, you'll have new options for those codes mentioned in this article:
Code V72.31 expands into two options: Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) and Z01.419 (... without abnormal findings).
Code V72.42 will become Z32.01 (Encounter for pregnancy test, result positive) Code V22.0 expands into four options: Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.04 (... third trimester).
Code V22.1 will include the four new codes listed above as well as four more: Z34.80 (Encounter for supervision of normal pregnancy, unspecified, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), and Z34.83 (... third trimester).
Code V22.2 will become Z33.1 (Pregnancy state, incidental).