Ob-Gyn Coding Alert

Question: How should I report the initial ob visit and preventive exam during the same visit, even though the pregnancy is the only complaint? One of my ob-gyns insists that this is acceptable, but CPT reads, "ante-partum care includes the initial and subsequent history, physical exams ..."

New York Subscriber

Answer: The American College of Obstetricians and Gynecologists (ACOG) has stated that if the patient comes in for an annual exam (99384-99386 for new patients, or 99394-99396 for established patients) and the ob-gyn diagnoses pregnancy, you still can bill for the annual examination. But then you should not start the ob record until the next visit because if you do, the whole visit will be considered part of the global ob service.

If the patient comes in for her annual examination knowing she is pregnant, the visit would be a low-level service (for example, 99212) to confirm pregnancy. If she is coming in with other complaints and you discover pregnancy, the work involved in eliminating the other possible diagnoses may constitute a higher-level E/M service (such as 99214). That work, however, has practically nothing to do with pregnancy except to confirm it with a test (for instance, 81025, Urine pregnancy test, by visual color comparison methods).

If this is not the scheduled annual visit, similar rules apply. If the patient comes in not knowing she is pregnant, you can bill for that visit, but you are only coding for the documentation that relates to diagnosing the pregnancy. If you initiate the ob record during that visit, the entire visit becomes part of the global period.

If the patient comes in knowing she is pregnant via a factual source (either another physician has confirmed pregnancy or the patient has a positive home pregnancy test), the service is part of the global ob package if you initiate the ob record during this visit. If, on the other hand, you simply "confirm the confirmation," you would be able to bill either the urine pregnancy test, if that was all the ob-gyn performed, or a low-level E/M service if some discussion with the patient takes place.