Ob-Gyn Coding Alert

Question: We have an ob patient who had an abnormal alpha-fetoprotein (AFP). My ob-gyn wants me to bill for a consultation because she was with the patient and husband for more than one hour, going over a quad screen. What is the dx for this?

Virginia Subscriber

Answer: Because this is a fetal problem, your primary diagnosis is 655.13 (Known or suspected chromosomal abnormality in fetus; antepartum condition or complication). Your second diagnosis code would be 796.5 (Abnormal finding on antenatal screening) for the abnormal finding.-

Note: If this is the ob's patient, you may not bill the service as a consultation. Instead, report an E/M code based on time, if counseling has dominated the total time of the visit. Make sure documentation describes the counseling content.