Ob-Gyn Coding Alert

Question: Our ob/gyn offices are having problems getting reimbursed for a well-woman exam performed on a patient during her first ob visit. This patient was due for her Pap smear and check-up, but also was newly pregnant. Can we or should we be billing for the well-woman exam? If so, do you suggest any specific coding techniques to help get reimbursed?

Nancy Preheim, Reimbursement Specialist
Unity Physician Billing, Chesterfield, Mo.

Answer: This question poses an interesting dilemma. To code correctly, you have to decide why the patient came to see the physician that day. Did she call to make her first ob appointment because she had a positive pregnancy test, or did she call to make an appointment for her annual exam? In the first instance, she has scheduled ob care. Despite the fact that she may also need a Pap specimen collected that day, the elements that normally would be part of an annual exam are also the same elements you would include with the initial obstetric history and physical that is part of the global package.

The only unusual thing would be the collection of the Pap smear specimen, but this should not be billed separately in any case, as it is part of the gynecologic examination. On the other hand, if the patient�s pregnancy is not diagnosed until the end of the scheduled annual exam, you may be able to code for the annual separately.

But let�s look at what usually happens next. Because you know by the end of visit that she is pregnant, you may be indicating a diagnosis of V22.0 (supervision of normal first pregnancy) or V22.1 (supervision of other normal pregnancy). If that were not enough, some practices even initiate the obstetric record at the visit for the annual exam, giving further proof that it should be considered part of the global ob care.

How do you avoid this problem and get paid appropriately for the annual exam? First, treat the visit for what it is. If it was scheduled as an annual exam, the ICD-9 code is V72.3 (gynecological examination), not supervision of pregnancy, even though you diagnosed pregnancy at this visit. Second, do not initiate the antepartum record at this visit. You should schedule the first ob visit on a different day.

Third, your medical documentation should include only the annual examination, but you can mention that a pregnancy test was performed and found to be positive. If, on the other hand, your patient comes in knowing she is pregnant and at that first ob visit a Pap smear is collected, there is nothing additional to bill for except the Pap smear interpretation, which probably will be billed by the laboratory, or alternatively, by your office on behalf of the lab, using modifier -90 (reference [outside] laboratory).