Wiki Prenatal flow records

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SHIBA425

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Has anyone audited a Prenatal Flow record for the documentation of prenatal E/M visits? Or an ACOG approved prenatal Record?

If so, when a patient presents for a routine prenatal follow-up visit with no problems, or concerns (just a plain prenatal visit) are you getting a 99212 or 99213. Now I realize it depends on what the provider documentes, lets say they only document :

FHR, fundal height, wks gestation, fetal movement, weight this visit, BP, edema, pain/pressure, and states no complaints. I would say a 99212.

Problems I have with this documentation are there is no Medical Decision Making documented. I am aware that you would only need 2 of 3 key components, but shouldn't there be something listed for MDM for some of these "routine" prenatal follow-ups? Also, the final diagnosis is not specifically stated in this note. I am not aware of any guideline that states you can infer or assume a diagnosis if it is not documented.

I posted this in the Auditing forum and no one has responded, I am hoping someone from the OB/GYN Forum can assist me.

Thanks Jeanne F.
 
OB Auditing

I'm looking for any information about doing Audits for Prenatal visits, both initial & follow ups. Does any one have up to date info, guidelines or resources that I can look into for this?

Thanks
 
I have the same question as Jeanne about routine OB checks that are documented in the prenatal flowsheet. I have not found any guidelines to indicate routine OB visits, that are documented in the PNFS are exempt from E&M coding guidelines. Am I missing something? Does someone have an example of a PNFS entry for a routine OB check that audits out to a 99213? It will be interesting to hear more on this subject.
 
Last time I coded for civilian type OB visits, all routine OB visits are included in the global package. The only time you'd be able to code for an E&M is, if there is a separately identifiable problem.
To qualify for an established E&M, 2 of 3 components in the E&M have to be met, one being the medical decision making.

http://www.trailblazerhealth.com/Specialty Services/Evaluation and Management/default.aspx?

This link has a wealth of E&M information for you.

Hope this helps.

Barb
 
@vbegay - send me a private message with your e-mail and I can send you an audit tool instruction sheet that may help.
 
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