Ob-Gyn Coding Alert

Find out what documentation you must have for each type of procedure Deciding between codes for routine and more targeted ultrasounds can be challenging, but the key to making the right choice is two-faceted: Look at the equipment your ob-gyn uses and the medical indications that prompted the procedure. Experts say this will help you narrow down your selection. Did you know? As many as 70 percent of women in the United States undergo a routine ultrasound (US) evaluation during their pregnancies, usually at 18-20 weeks- gestation. In fact, the American College of Obstetricians and Gynecologists (ACOG) maintains that physicians should include one complete US as a part of routine obstetric care. Impact: You must be certain you make the distinction between regular and detailed ob ultrasounds in your claims every time. If your practice undergoes an audit, incorrect coding may mean your payer could take reimbursement back.
Review Indications for Routine US When a patient presents with suspected uterine or placenta abnormalities, you shouldn't automatically leap to the conclusion that the ob-gyn performed a complex US. These abnormalities are among the indications for a routine US.

Indications: When your ob-gyn performs a US on an ob patient in her second or third trimester, he may do this for one or several reasons. According to Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M., ultrasounds can estimate gestational age and fetal weight, determine fetal presentation, and provide the ob-gyn with evaluations of any number of the following aspects: fetal growth uterine size (date discrepancies) fetal life suspected uterine abnormality abnormal alpha-fetoprotein (AFP) suspected poly/oligohydramnios suspected abnormalities of placenta vaginal bleeding/amniotic fluid leakage follow-up of suspected fetal anomalies patients with history of prior congenital anomalies. Code a routine US based on the number of fetuses with 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) and possibly +76810 (... each additional gestation [list separately in addition to code for primary procedure]). You should identify the reason for the scan using the appropriate ICD-9 code. If this ultrasound is a routine screening, you should use only V28.3 (Screening for malformation using ultrasonics). If the physician has reason to believe there is a problem with the fetus, use the 655 category code that identifies that reason. For instance, you might use 655.83 (Other known or suspected fetal abnormality, not elsewhere classified; antepartum condition or complication).

Test Yourself With This Scenario Scenario: A 35-year-old patient presents at 18 weeks gestation with decreased amniotic fluid. The ob-gyn suspects fetal renal anomalies and performs a routine ultrasound. You should report 76805.

If the same [...]