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, am I to assume this is a pregnancy-related complication?

Georgia Subscriber

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.