Wiki How can primary care see a patient regarding her pregnancy without it being denied as part of the OB package?

[kimberagame]

We occasionally get pregnant mothers coming in needing referrals to an OB. They don't need a pregnancy test, so I can't use a Z32 code. The pregnancy is the reason they're there, so I can't use the incidental pregnancy code, Z33.1. The only appropriate codes I've ever found are the Z34 supervision of pregnancy codes, or an O code depending on the mother's health. These always get denied as being part of the delivery package. I haven't been able to find a modifier that seems appropriate to indicate this is outside of the package. Nothing I've found online has addressed this situation. Does anyone have any suggestions or something different that their clinic does? Thanks for any insights!

 

[SharonCollachi]

Okay, I'll bite. Why don't they need a pregnancy test? Doesn't the doctor have to evaluate whether or not the patient actually needs a referral?

 

[kimberagame]

The visit that prompted this question was a woman who was already being seen by an OB, but her insurance changed and she needed a new referral to a different OB. Another case that comes to mind is a woman who was advanced in her pregnancy and had received no care. She came to us expecting our provider to manage her care. Apparently the provider did not feel a test was necessary in that case, or the patient declined one. There have been other cases, but they're few and far between. Just really annoying when they pop up and I know we're probably not going to be reimbursed for it.

 

[SharonCollachi]

The visit that prompted this question was a woman who was already being seen by an OB, but her insurance changed and she needed a new referral to a different OB. Another case that comes to mind is a woman who was advanced in her pregnancy and had received no care. She came to us expecting our provider to manage her care. Apparently the provider did not feel a test was necessary in that case, or the patient declined one. There have been other cases, but they're few and far between. Just really annoying when they pop up and I know we're probably not going to be reimbursed for it.

Unless they're in an HMO, they don't need a referral to an OB, do they? Can't they self-refer? Well, in my state even with an HMO they can self-refer to OB. In your first scenario, I would think the OB that was treating them should do the referral, since they have all the records.

For most of these, I would probably do it as a self-pay visit, or handle it over the phone.