Ob-Gyn Coding Alert

Question: An ob patient comes in for a routine visit. During the course of her visit, she complains of sciatica. How would you code this visit? Do I code for an evaluation and management (E/M) visit or is this part of her prenatal visit?

Alicia Johnson
Drs. Esposito, Mayer, Hogan & Assoc., P.A.
Columbia, Md.

Answer: Any time a physician has performed a significant and separately identifiable E/M service at the time of other services, the E/M service can be billed, according to CPT guidelines.

The key to payment will be documentation. If the treatment or mention of sciatica appears buried in the antepartum record, you would have difficulty getting the claim paid. On the other hand, if the physician has created a separate E/M note detailing the work involved in evaluating and managing this condition, you can code for an E/M service on the same day as the routine antepartum exam.

Your diagnosis coding will be 724.3 for the sciatica plus V22.2 (pregnant state, incidental). Because you will not be billing for the antepartum visit, which is included in the global period, you may decide not to add modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day) to the E/M code. Correct coding per CPT would indicate that you should, just to be accurate.