Ob-Gyn Coding Alert

Question: My ob-gyn admitted a pregnant patient at 40 weeks who was in labor. She received Pitocin for 8 hours, but because she exhibited no cervical change, the ob-gyn discharged her. Can I bill for the hospital visit and the Pitocin or only the hospital visit?

Colorado Subscriber

Answer: You should report the hospital visit only (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) -- unless the physician personally started the IV and stayed with her the whole time (which almost never happens). The codes for performing an IV infusion are 96365-96366, and to report them, the ob-gyn must document the length of time of the infusion.

If the ob-gyn admitted and discharged the patient the same day, you should not report the normal hospital admit codes, but instead report 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...).