Primary Care Coding Alert

Question: Recently, we had a newly pregnant patient come in for her preventative well-woman exam. We officially diagnosed her at that exam. Can I still report the patient’s annual exam?

Ohio Subscriber

Answer: Yes. The annual visit is what the patient was coming in for, so you should definitely report that. You will also code the diagnostic test to confirm the pregnancy.

Remember to link the pregnancy diagnosis to the test, not the annual examination. Your claim should look like this:

• The diagnostic test, such as 81025 (Urine pregnancy test, by visual color comparison methods) linked to the pregnancy exam diagnosis: Z32.01 (Encounter for pregnancy test, result positive)
• The annual exam code, 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)) -99386 - (… 40-64 years) for new patients, or 99394 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/ risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)) -99396 (… 40-64 years) for established patients) linked to Z01.411 (Encounter for gynecological examination (general) (routine) with abnormal findings) or Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal findings). Note that a positive pregnancy test does not count as an abnormal finding.

Caution: You would not normally also bill for a low-level service (such as 99211) under this circumstance unless there was a significant and separate evaluation and management (E/M) service related to the pregnancy at this annual visit. In most cases, the physician will merely confirm the home pregnancy test and schedule the patient for maternity care at the next visit. But keep in mind that if the pregnancy is being evaluated or managed, the payer may include the entire visit as part of global maternity care (e.g., 59400 (Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care).