Can someone help me understand the difference or can you share any coding resources. Just want to make sure if a provider can bill a separate E/M for confirmation of pregnancy or considered to be initial OB. Patient saw her PCP via telemedicine prior who diagnosed Amenorrhea with positive home pregnancy test and referred to follow up with OB. To continue with prenatal vitamins.
But PCP didn't order a test to confirm pregnancy besides the patient doing a home test. Just the referral to OB. I want to make sure the OB provider can bill an E/M and not considered this visit the initial OB. I have read where it states if OB started the prenatal record then this would be considered the initial OB, how would I know that?
here is the visit:
31 y.o.-year-old female presents for confirmation of pregnancy. She has irregular menses. LNMP was on 1/3/21? Denies hematuria or hematochezia. Denies bowel and bladder changes.
Ob/gyn hx: G1
Physical exam:
The patient declines nurse presence for examination
Blood pressure 143/82, pulse 118, height 5' 2" (1.575 m), weight 156 lb (70.8 kg), last menstrual period 01/03/2021.
General: alert and oriented and in no acute distress
Abdomen: soft nontender to palpation, positive bowel sounds. No hernia
Pelvic Exam:
Deferred
PSYCHIATRIC: alert and oriented to time, place and person
UCG+
Obstetrical Ultrasound:
Single IUP with AUA consistent with 6-7 weeks. Positive cardiac motion. Measurements sub-optimal on abdominal scan, she declines vaginal scan
Assessment:
1. Amenorrhea:
Prenatal Profile I, UA/M w/rflx Culture, Routine, HIV 1/0/2 Antigen/AB 4th Generation
2. early pregnancy at 6-7 weeks
I spent 30 minutes reviewing the patient's diagnostic tests, labs, examining the patient, counseling the patient, reviewing the treatment options/plan and documenting in the medical record.
But PCP didn't order a test to confirm pregnancy besides the patient doing a home test. Just the referral to OB. I want to make sure the OB provider can bill an E/M and not considered this visit the initial OB. I have read where it states if OB started the prenatal record then this would be considered the initial OB, how would I know that?
here is the visit:
31 y.o.-year-old female presents for confirmation of pregnancy. She has irregular menses. LNMP was on 1/3/21? Denies hematuria or hematochezia. Denies bowel and bladder changes.
Ob/gyn hx: G1
Physical exam:
The patient declines nurse presence for examination
Blood pressure 143/82, pulse 118, height 5' 2" (1.575 m), weight 156 lb (70.8 kg), last menstrual period 01/03/2021.
General: alert and oriented and in no acute distress
Abdomen: soft nontender to palpation, positive bowel sounds. No hernia
Pelvic Exam:
Deferred
PSYCHIATRIC: alert and oriented to time, place and person
UCG+
Obstetrical Ultrasound:
Single IUP with AUA consistent with 6-7 weeks. Positive cardiac motion. Measurements sub-optimal on abdominal scan, she declines vaginal scan
Assessment:
1. Amenorrhea:
Prenatal Profile I, UA/M w/rflx Culture, Routine, HIV 1/0/2 Antigen/AB 4th Generation
2. early pregnancy at 6-7 weeks
PLAN:
Prenatal lab panel, PAP and genital cultures
Start prenatal vitamins Prenatal lab panel, PAP and genital cultures
I spent 30 minutes reviewing the patient's diagnostic tests, labs, examining the patient, counseling the patient, reviewing the treatment options/plan and documenting in the medical record.