Ob-Gyn Coding Alert

The table also includes four levels of risk: minimal, low, moderate and high.

Review the following examples of conditions and treatments that meet Medicare requirements:

1. Minimal. Your ob-gyn treats a minor problem, such as a scrape. Diagnostic procedures that meet the "minimal" criteria include laboratory tests requiring venipuncture, x-rays, urinalysis or ultrasounds.

Management options include rest and simple bandages.

2. Low. Typically, the patient presents with two or more minor problems, one chronic illness or an acute uncomplicated illness. Diagnostic procedures consist of superficial needle biopsies, laboratory tests that require arterial puncture, noncardiovascular imaging studies such as a barium enema, and physiologic tests not under stress. Management options include over-the-counter medications and minor surgery with no risk factors.

3. Moderate. The ob-gyn treats one or more chronic illnesses with mild exacerbation, two or more stable chronic illnesses, an undiagnosed problem, acute illness with systematic symptoms, or an acute complicated injury. For instance, a patient may present with gestational diabetes (648.83) and hypertension (401.x). In this level, diagnostic procedures consist of physiologic tests under stress, diagnostic endoscopies with no risk factors, deep needle or incisional biopsy, cardiovascular imaging studies with contrast and no risk factors, and obtaining fluid from the body.

Management options include minor surgery with identified risk factors, elective major surgery with no risk factors, and prescription-drug management.

4. High. The patient has one or more chronic illnesses with severe exacerbation or progression, acute or chronic illnesses or injuries that may pose a threat to life or bodily  function, or an abrupt change in neurologic status.

Diagnostic procedures include imaging studies with contrast and identified risk factors, and cardiac electrophysiological tests. Management options consist of elective major surgery with risk factors, emergency major surgery, and drug therapy requiring intensive monitoring for toxicity.

"One trick I know that helps our physicians is to focus primarily on the treatment or management options portion of the chart," says Jaime Darling, CPC, a certified coder for Graybill Medical Group in Escondido, Calif.

You should select a risk level based on the highest single criterion the ob-gyn has met, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Quick quiz: A patient presents with a low-level risk under the Table of Risk's "Presenting Problem(s)" category, such as vaginal discharge (623.5, Leukorrhea, not specified as infective). The ob-gyn swabs the discharge material and sends it to the lab for testing, which qualifies as a minimal level of risk under "Diagnostic Procedure(s) Ordered." But then the physician selects a moderate risk level of "Management Options," such as prescribing an antibiotic. What level of risk should you assign in this case?

In any case, a higher level of risk may affect the medical decision-making complexity and change the E/M code you report.

The answer: If you undervalued the ob-gyn's management options, which involved prescribing antibiotics, you may have determined that the visit had a low risk and reported a lower-level E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...), which pays roughly $40, according to national Medicare averages. But with the visit having a moderate risk, you may be able to report a higher-level code, such as 99213, which pays $55. "If the doctor writes or deals with prescriptions, he often doesn't realize that this falls under moderate," Darling says.

Remember that medical decision-making involves more than just risk, Pohlig points out. Just as there are three categories of risk, there are three categories of medical decision-making to consider before selecting the final complexity level. These categories are number of diagnoses/treatment options, amount and/or complexity of data ordered/reviewed, and risk of complications and/or morbidity/mortality. You must meet or exceed two of the three categories associated with a certain complexity level to select that level of complexity, Pohlig says.