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Answer: It would be appropriate to report the encounter with the preventive-medicine code applicable to the age and status of the patient (i.e., new or established). For instance, if the woman is 28 years old and has been seen in the practice within the previous three years, you should report 99395 (periodic preventive medicine, established patient; 18-39 years). Diagnosis code V70.0 (routine general medical examination at a healthcare facility) should be linked to the exam, as well as V72.3 (gynecological examination) if those services are provided.
Although findings indicating the pregnancy will be documented in the patient record at this visit, the family physician should also indicate that the initial obstetric history and physical were not performed. Instead, the patient should be advised to schedule a second visit on a different date for those services. At that visit, the standard pregnancy history and physical exam will be done and the official ob record initiated. If the family physician anticipates providing all the prenatal, delivery and postpartum care, this subsequent visit would be included in the global package reported when the service is complete, e.g., 59400, routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
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