Wiki Auditing global prenatal visits

[leskew01]

We provide global maternity care for OB patients and typically bill 0502F (non-Medicaid). Say for instance, the patient has pre-existing diabetes and lists it as a diagnosis on the prenatal flow sheet. Patient comes in for a routine prenatal visit (0502F) but doesn't mention anything about the diabetes....can I still attach the pre-existing diabetes diagnosis on that visit even though it wasn't addressed at that visit but was found on the flow sheet?

I get that a visit note must stand alone....but this is part of global OB care and that prenatal flow sheet is documenting all her antepartum care.

Thanks for any input!

 

[Chelle-Lynn]

In our office we would say no. Unless the physician monitored or treated her for that condition during her OB visits we would not. If the only reference is by the patient and nothing is documented from the physician to substantiate this diagnosis and no treatment/monitoring was provided, we would not add this code as a definitive or treated diagnosis.