Ob-Gyn Coding Alert

Question: I need help with a diagnosis for this follow-up visit after surgery in the ER which our doctor did not perform. Can I use 59430 with Z39.2? My next option was to bill an E/M using Z09 as primary and Z87.59 for the secondary. Would that cover the lab for the HCG? I am providing the Chart notes for help. Thank you so very much!

Patient is being seen today following up for threatened miscarriage in early pregnancy. She is G2P1101 at 8 and 2/7 weeks gestation and was dated by 6w1d ultrasound with an EDD of 5/7/2017.

Patient reports last Tuesday she was seen in the ER for increasing abdominal pain which woke her from sleep around 2AM. While in the ER they suction vacuumed her out. She denies any more bleeding since that time. She is wondering when she will be off pelvic rest. She plans to use condoms for birth control.

OBJECTIVE:

BP 120/70 mmHg | Wt 67.586 kg (149 lb) | LMP 07/11/2016
Physical Examination: General appearance - alert, well appearing, and in no distress
Eyes - pupils equal and reactive, extraocular eye movements intact
Neck - supple, no significant adenopathy
Chest - clear to auscultation, no wheezes, rales or rhonchi, symmetric air entry
Heart - normal rate, regular rhythm, normal S1, S2, no murmurs, rubs, clicks or gallops
Abdomen - soft, nontender, nondistended, no masses or organomegaly
Back exam - full range of motion, no tenderness, palpable spasm or pain on motion
Musculoskeletal - no joint tenderness, deformity or swelling
Extremities - peripheral pulses normal, no pedal edema, no clubbing or cyanosis
Skin - normal coloration and turgor, no rashes, no suspicious skin lesions noted

ASSESSMENT:

Encounter Diagnosis 
Name Primary?  
Follow-up visit after miscarriage Yes 

PLAN:

Orders Placed This Encounter 
BETA HCG QUANTITATIVE, BLOOD 

--> Patient instructed to not place anything into the vagina, including sex for 4 to 6 weeks. She is not to attempt getting pregnant again until 3 months have passed since miscarriage. Instructed to call the office if she has any questions or concerns. Patient plans to use condoms as her method of birth control. Patient will follow up in 1 week for lab only to check her HCG level.

Coding Institute Forum Subscriber

Answer: You have the option of billing the surgical code they used in the ER for the evacuation with a modifier 55 (Postoperative management) as you are providing the postop care. To find out which code to report, you will need to access this information from the provider who did the procedure. But at 6 weeks, it is likely that they reported code 59812 (Treatment of incomplete abortion, any trimester, completed surgically). Or you can bill just an E/M code (99201-99212, Office or other outpatient visit …).

Your diagnosis for the visit is not routine postpartum care since this was a miscarriage. You would instead report Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) plus Z87.59 (Personal history of other complications of pregnancy, childbirth and the puerperium), as you have indicated as your second option.