Ob-Gyn Coding Alert

Question: One of our clients wants to know whether she should charge an E/M visit or bill globally for an initial ob visit. The ob-gyn thinks it's illegal to charge an E/M code because the ob-gyn did not start a flow sheet for this particular initial visit. I've tried to explain that she can report an E/M visit, but I was wondering if you have some information on the subject.


New York Subscriber

Answer: The perspective of the American College of Obstetricians and Gynecologists (ACOG) is that billing a visit prior to establishing a diagnosis of pregnancy is not illegal.
 
The global code includes the initial history and physical, but it does not include the diagnosis of pregnancy. The only time this first visit is part of the global service would be when the ob-gyn initiated the ob record at that visit.
 
During the visit when the ob-gyn diagnoses pregnancy, however, you won't have enough documentation to report a comprehensive exam and history or to support complex medical decision-making. In other words, you will not have a level-four or level-five E/M service on your hands.

ACOG encourages physicians to use 626.8 (Missed period) as the diagnosis for the E/M visit.
 
However, ICD-9 rules disagree because they state you must code for what you know at the end of the visit. If she comes in with missed periods and leaves with a diagnosis of pregnancy, you should code V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) under their rule system.  

Doing this, however, frequently results in the player including this visit as part of the global service. But if you look at most benefit policies, you will see that diagnosing pregnancy is a separately billable service.

Common sense: You wouldn't include the E/M service when a physician makes a diagnosis that indicates same-day surgery in the code for the surgery. Likewise, the diagnosing of pregnancy is not an integral part of the ob global package.

If a patient calls because she thinks she might be pregnant, you may simply do the urine test. If she is pregnant, you bill the test only and then schedule her first ob visit.

If the test is negative, she will need to see the physician for her complaint.
 
If the patient comes in knowing from a credible source that she is pregnant, you should include the first visit as part of the global care.

For more references, see the August 2002 CPT Assistant or "Don't Miss Out on E/M Fees by Initiating the Ob Record Too Soon" in the July 2005 Ob-Gyn Coding Alert.