OB Global Clock
By Chris Owens, CPC and Suzanne Leder, MPhil, CPC-A
Your diagnosis coding for a new pregnancy can get tricky, especially when you have to decide between annual visits and nonscheduled exams. But if you pay attention to certain key elements, you’ll know exactly when to begin the OB record.
The keys: There are three things you need to consider when you’re deciding whether to begin the OB global package:
• If a patient’s annual visit leads to a diagnosis of her pregnancy.
• If she arrives knowing she is pregnant.
• If your physician eliminates other possible diagnoses.
Use the following scenarios to determine when you should begin the OB record.
Examine Your Annual Visits
Scenario 1: Your physician diagnoses pregnancy during a patient’s annual exam.
Answer 1: You should wait until the next visit to start the OB global package, otherwise your carriers will consider the whole visit part of the OB record. Plus, the reason for the patient’s visit is her annual exam (99384-99386 for new patients or 99394-99396 for established patients), and your physician incidentally learns that she is pregnant during the visit. Keep in mind that if your physician diagnoses pregnancy (V72.42, pregnancy examination or test, positive result) during a patient’s annual exam, you can still report the annual examination as long as you link the pregnancy diagnosis to the diagnostic test (for example, 81025, urine pregnancy test, by visual color comparison methods).
Here’s the rule: You must report what you know at the end of any visit. If your physician knows the patient is pregnant, you must report the patient as pregnant. But you don’t have to use code V22.0-V22.1 (supervision of normal pregnancy) because your doctor is not supervising the pregnancy during this annual exam visit. You also have the option of using V22.2 (pregnant state, incidental), but in general, V72.42 qualifies the pregnancy test as an incidental finding.
What if She Knows She’s Pregnant?
Scenario 2: The patient arrives for her annual exam, and she already knows she’s pregnant.
Answer 2: As with the previous scenario, the patient is there for her annual exam, and not for a prenatal visit. Therefore, her pregnancy is incidental to her well woman service.
In other words: You should not begin the OB record until the patient schedules a full visit with your physician for the initial obstetric exam and counseling. Once you start the OB global clock, all visits, including the initial encounter with your physician, count toward the total for global care, which usually includes 13 outpatient antepartum visits. In this case, you should code the annual exam as you normally would and link the encounter to V72.31 (Routine gynecological examination). If your physician performs a second pregnancy test (such as 81025) to confirm that the patient is pregnant, you can link the test to V72.42 or V22.2.
Wait Until Next Time With Complaint Visit
Scenario 3: A patient comes in for her annual exam but has other complaints, and your physician discovers that she’s pregnant.
Answer 3: You won’t start the OB record during this visit because your physician’s work associated with this service does not focus on or relate to the pregnancy, except to confirm it with a test. Therefore, if your doctor makes other diagnoses in addition to the pregnancy, you should not list V22.0-V22.2 as your principal diagnosis. Your physician can start the OB record at the next visit.
Test Results Don’t Eliminate OB Global Option
Scenario 4: A patient sees her physician and complains of abdominal cramping, sweating, having missed a period, or other possible pregnancy symptoms. Consequently, your doctor orders a
pregnancy test and learns that she is pregnant.
Answer 4: Because the patient’s symptoms related to a problem that turned out to be pregnancy, you should report your physician’s services as an outpatient office visit (99201-99205 for new patients or 99211-99215 for established patients). If your physician evaluates other possible problems (that eventually reveal the patient is pregnant), you should report this service outside the OB record. As in the previous scenarios, you can report the patient’s symptoms to establish medical necessity for the visit, but be sure to link V72.42 to the lab test that confirms the pregnancy. You should include the other diagnoses for the chief complaint — such as nausea (787.02), bloating (787.3) or weight gain (783.1) — with the office visit code.
Complaints and Home Test Results Mean Start Now
Scenario 5: The patient arrives for her visit with complaints related to pregnancy and states that her home pregnancy test indicates she’s pregnant. In response, your physician determines that her complaints are indeed a result of pregnancy.
Answer 5: In this case, you would begin the OB record with this visit because the patient is presenting for pregnancy care. If the patient’s chief complaint is that she’s pregnant, you should start the OB global period. Your diagnosis for this visit would be V22.0 or V22.1.
Home Test Results Present Two Options
Scenario 6: A patient arrives at your office knowing that she’s pregnant because her home pregnancy test was positive.
Answer 6: If your physician simply confirms the positive home pregnancy test, you should code according to the method he uses. For example, if the physician uses the urine pregnancy test, you would report 81025. If the physician performs a low-level E/M service with some discussion with the patient, you might submit 99201 or 99212. On the other hand, if your physician initiates the OB record during this visit, you should include it as part of the global package.
This article was prepared with the assistance of Melanie Witt, RN, CPC, MA, an independent coding consultant based in Guadalupita, N.M. Chris Owens, CPC, has worked for The Coding Institute LLC since 1999 and has written coding education newsletters for several specialties including OB/GYN and pulmonology. He is currently the managing editor for 10 Coding Alert newsletters, which bring specialty-specific coding news and advice to roughly 60,000 readers. Owens also served as the AAPC’s past president for the Fort Myers, Fla., City of Palms chapter and is on the advisory committee for the Lee County High-Tech Center North coding curriculum. Suzanne Leder, MPhil, CPC-A, has worked for The Coding Institute since 2004 and currently writes three coding education newsletters: OB/GYN Coding Alert, Cardiology Coding Alert and Gastroenterology Coding Alert.
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