Ob-Gyn Coding Alert

Hint: You must code what you know at the end of the visit

Coding for the clinical diagnosis of a pregnancy can be complex when you have to decide between annual visits and nonscheduled exams. Take this six-question challenge, and see whether you-ve got when to begin your ob records down pat.
 
Key: When you-re trying to decide whether to begin the ob record, examine these three scenarios: (1) if a patient's annual visit leads to a diagnosis of her pregnancy, (2) if she arrives knowing she is pregnant, or (3) if the ob-gyn eliminates other possible diagnoses.

Analyze These Annual Visit Questions

Question 1: The ob-gyn diagnoses pregnancy during a patient's annual exam. Should you begin the ob record at this visit?
 
Answer 1: No. You should not begin the ob record until the next visit. Otherwise, carriers will consider the whole visit part of the global ob service (59400, 59510, 59610, 59618). Rationale: -The reason for the visit is the -annual exam,- and incidentally the ob-gyn learns the patient is pregnant during the visit,- says Shari Kheul, CCS-P, coding and reimbursement specialist at Women's Health Services in Clinton, Iowa.
 
Remember: If the ob-gyn diagnoses pregnancy (V72.42, Pregnancy examination or test, positive result) during a patient's annual exam (99384-99386 for new patients, or 99394-99396 for established patients), you can still report the annual examination, as long as you link the pregnancy diagnosis to the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods).
 
Rule: You must report what you know at the end of any visit. If the ob-gyn knows the patient is pregnant, you must report the patient as pregnant, but you do not have to use codes V22.0-V22.1 (Supervision of normal pregnancy) because the ob-gyn is not supervising the pregnancy at this visit. Also, you have the option of using V22.2 (Pregnant state, incidental). In general, V72.42 qualifies the pregnancy test as an incidental finding.

Question 2: The patient comes in for her annual examination, already knowing she is pregnant. Should you begin the ob record at this visit?
 
Answer 2: No. -Again, the patient has come in for an annual exam, not a prenatal visit. Therefore, the pregnancy would be incidental to the well-woman code,- says Jennifer Ohmart, CAP, medical, claims and insurance specialist at Billing Bee in Lakewood, Calif.
 
In other words, you should not begin the ob record until the patient schedules a full visit with the ob-gyn or certified nurse midwife (CNM) for the initial obstetric exam and counseling. All visits, including the initial encounter with the physician or the CNM, count toward the total for global care, which generally includes 13 outpatient antepartum visits.
 
You will code the annual exam as you normally would and link the encounter to V72.31 (Routine gynecological examination). If the ob-gyn performs a second pregnancy test to confirm what the patient already knows (such as 81025), you can link that test to V72.42 or V22.2.

Question 3: The patient presents for her annual exam but has other complaints, and the ob-gyn then discovers pregnancy. Should you begin the ob record at this visit?
 
Answer 3: No. The work of this exam does not focus on or relate to the pregnancy, except to confirm it with a test (like 81025). Therefore, if the ob-gyn makes other diagnoses in addition to the pregnancy, you should not list V22.0-V22.2 as the principal diagnosis. -The ob-gyn can start the ob record at the next visit,- Ohmart says.
 
Also, the work involved in eliminating other possible diagnoses may constitute a higher-level E/M service (such as 99214, Office or other outpatient visit for an established patient ... 25 minutes face-to-face).

Test Results Don't Always Mean No Ob Record

Question 4: The patient sees her ob-gyn for abdominal cramping, sweating, having missed a period, or for other possible symptoms. These complaints prompt the ob-gyn to order a pregnancy test (like 81025). He learns from the results that she is pregnant. Should you begin the ob record at this visit?
 
Answer 4: No. You should report an E/M service because the symptoms are related to a problem that turned out to be pregnancy. If the ob-gyn evaluated other possible problems (which eventually revealed the pregnancy), you should report this service outside the global ob package.
 
Once again, you can report the symptoms she presented with to establish the medical necessity of the visit, but link V72.42 to the lab test that confirms the pregnancy. -So include the diagnoses for the other complaints such as nausea (787.02), bloating (787.3) or weight gain (783.1),- Ohmart says.

Question 5: If the patient comes in with complaints related to pregnancy and states that her home pregnancy test shows she is pregnant, the ob-gyn will determine whether these complaints relate to the pregnancy. Should you begin the ob record at this visit?
 
Answer 5: Yes. If these complaints do relate to her being pregnant, you should code the service as part of the global ob package because the patient is presenting for pregnancy care. If the chief complaint of the patient -quot; or in other words, the signs and symptoms -quot; is that she is pregnant, the ob record would begin. The diagnosis in this case will be V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy).
 
Bottom line: If your ob-gyn initiates the ob record during that visit, the entire visit becomes part of the global period.
 
Question 6: The same patient arrives knowing that she is pregnant because her home pregnancy test was positive. Should you begin the ob record at this visit?
 
Answer 6: Maybe. If the ob-gyn simply confirms the positive home pregnancy test, you should code by the method used to confirm the pregnancy. This method might include either the urine pregnancy test (81025) if the ob-gyn performs one, or a low-level E/M service if some discussion with the patient takes place. If your ob-gyn instead initiates the ob record at this visit, this visit is part of the global period.
 
-If a patient comes into our office knowing she is pregnant, we will do a urine pregnancy test (81025), and if the results are positive, one of our nurse practitioners sees the patient and talks to her,- Kheul says. -This is usually a brief visit to discuss her plans for the pregnancy and get her started on prenatal vitamins; this is not to start a prenatal record. Afterward, we schedule the patient to come back for a prenatal exam and start the ob record then.-