Ob-Gyn Coding Alert

Question: When an ob patient presents to the office for her routine visit and complains of sinus related symptoms, the physician determines it is a sinus infection and writes a prescription. Unless the physician tells me this is unrelated to the pregnancy, I am to assume this is a pregnancy related complication?

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Answer: Yes, this is the instruction in the guidelines: “Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1 (Pregnant state, incidental) should be used in place of any chapter 15 codes.” Therefore, it is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.