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Ob-Gyn Coding Alert

Reader Question:

Complications Have to Affect Ob Care

Published on Wed Mar 07, 2012

Question: My ob-gyn saw a patient for a routine ob visit at 11 weeks 3 days GA. In the history portion, he notes that she is experiencing some nausea. She takes Unisom, which seems to help with the nausea. Otherwise, the patient is fine (no dizziness, no other complaints, feels well), and the exam is normal. The ob-gyn does note that she has a low blood pressure at 90/60, but he qualifies this as a normal pregnancy visit. We're wondering if we should code this as a complication, because the patient has nausea and is taking Unisom. Do we have any complication diagnosis? The ob-gyn does not state the nausea was affecting the pregnancy. How about the low blood pressure? Tennessee SubscriberAnswer: You should examine the ob-gyn's notes. Ask, did the ob-gyn provide routine ob care, or did the ob-gyn do something to manage the patient's complaint or serious finding?Most [...]
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