Ob-Gyn Coding Alert

Question: We did a pelvic ultrasound on a patient due to pelvic pain and discovered the patient is pregnant. I know I should use 76856, but do I stick with the R10.2 and then use incidental pregnancy finding, or do I use O99.89 and R10.2? Thank you!

Kansas Subscriber

Answer: You are correctly coding this as a gynecology examination, so the diagnosis would be the reason for the scan initially (R10.2, Pelvic and perineal pain) with a secondary diagnosis of either the finding (pregnancy test positive: Z32.01, Encounter for pregnancy test, result positive) or pregnancy incidental: Z33.1 (Pregnant state, incidental).