Ob-Gyn Coding Alert

Question: Is there some documentation out there showing that a “confir­mation of pregnancy visit” should be a low level visit (99212- 99213)?

Texas Subscriber

Answer: The rationale is that a visit that is only for confirmation of pregnancy will entail straightforward medical decision making (MDM) in most cases but could be low MDM in some cases. Even if the physician decided to do a full blown exam and history at this confirmation visit, it would not be warranted due to the nature of the presenting problem if the visit was only for confirmation. This is common sense, and you will find no published documentation criteria for this type of visit. But as always, the documentation must support the level of visit billed that is still in keeping with MDM as the foundation for the visit.