Is an E&M is appropriate to bill when this patient came in for a routine OB check up and has a problem. I have been looking at ACOG guidelines and struggling to find firm information on if an E&M is warranted. The argument is that the BV was a complication of the pregnancy and a prescription was ordered. The opposing view is that it was a scheduled, routine OB visit and is a complication of the pregnancy and should be included in the global package.
"Patient is doing well today. She is doing her glucose testing and hemoglobin test today. She is having some round ligament pain. No contractions, bleeding, or fluid leaking. She is also complaining of some greenish discharge that is irritating. We will send a prescription for MetroGel for presumed bacterial vaginosis. Intercourse is also uncomfortable. We will plan to see her back in 1 month again."
"Patient is doing well today. She is doing her glucose testing and hemoglobin test today. She is having some round ligament pain. No contractions, bleeding, or fluid leaking. She is also complaining of some greenish discharge that is irritating. We will send a prescription for MetroGel for presumed bacterial vaginosis. Intercourse is also uncomfortable. We will plan to see her back in 1 month again."