Ob-Gyn Coding Alert

Good advice: Remember to fully document pessary visits, says Nicole Martin, billing coordinator at The Institute for Female Pelvic Medicine & Reconstructive Surgery in Allentown, Pa. "I see these visits undercoded many times because the physician does not fully document common ailments such as excoriations and ulcerations as well as vaginal infection," she says.

Result: Incomplete documentation can lead to much lower E/M codes.-"When we get into the day-to-day monotony of our practices, we fail to realize that prolapsed pelvic organs are not a -routine- issue and many times require a higher medical decision-making (MDM) than we would think."

Strategy: "In our practice, we use a form for pessary follow-up visits that has a range of choices to describe common pessary issues. This helps to curb under-documentation and supports the E/M codes we are using," Martin says.