pclaybaugh
Networker
Auditing OB, I routinely see 0502F and an E/M visit, in this case 99213 billed together. This patient is considered obese. the encounter reads:
Obesity complicating pregnancy, third trimester
seen today for ROB
Doing well
Obesity- reviewed early 1hr GTT- WNL, discussed with patient that per her glucose log would diagnose her with GDMA1 however gold standard for diagnosis of GDM is to start with 1hr GTT followed by 3 hr GTT if needed. Pt agreed to complete 1 hr GTT, will follow up as needed. Ordered today
Advised pt to complete CBC and RPR as well
Reviewed how to perform FKC
Reviewed signs and symptoms of PTL to include more than 6 contractions/hour, LOF, vaginal bleeding. Access to care reviewed
Advised TDAP
Advised pt to follow up in 4 weeks. Reviewed travel precautions
Ordered:
*Glucose Level 1 Hour 50g
Referral Request
I maintain the 99213 is not mandated. This isn't an acute problem and it is expected to gain weight during pregnancy. This is why we don't use the BMI, would like OB coders to weigh in, please.
Many thanks.
Obesity complicating pregnancy, third trimester
seen today for ROB
Doing well
Obesity- reviewed early 1hr GTT- WNL, discussed with patient that per her glucose log would diagnose her with GDMA1 however gold standard for diagnosis of GDM is to start with 1hr GTT followed by 3 hr GTT if needed. Pt agreed to complete 1 hr GTT, will follow up as needed. Ordered today
Advised pt to complete CBC and RPR as well
Reviewed how to perform FKC
Reviewed signs and symptoms of PTL to include more than 6 contractions/hour, LOF, vaginal bleeding. Access to care reviewed
Advised TDAP
Advised pt to follow up in 4 weeks. Reviewed travel precautions
Ordered:
*Glucose Level 1 Hour 50g
Referral Request
I maintain the 99213 is not mandated. This isn't an acute problem and it is expected to gain weight during pregnancy. This is why we don't use the BMI, would like OB coders to weigh in, please.
Many thanks.
