Ob-Gyn Coding Alert

Editors Note: Although this case focuses on multiple visits to address the problem of infertility, the same principles of coding apply to the accurate reporting of any multiple-visit problem. If you have a case youd like to submit for consideration, please send it via fax, email or mail.

A 27-year-old female patient was sent by her family physician for a consult to an ob/gyn for evaluation of possible infertility. She had been unable to conceive after more than one year of intercourse without contraception.

After a complete work-up on October 4, including a comprehensive history, comprehensive physical examination, and face-to-face review of the medical records, an initial evaluation was planned and carried out. The evaluation included a semen analysis, hysterosalpingogram (HSG), endometrial biopsy, serum progesterone, and review of basal body temperature curve. An endometrial biopsy was performed on the day of the first visit and the HSG was scheduled for three days later at the hospital radiology department.

The patient was seen one week later in the office to review the results of testing and go over the plan of management (the visit lasted 30 minutes). Anovulation was diagnosed, and the patient elects to be treated with six cycles of clomiphene citrate. The day before this encounter, the doctor informs the family physician of his findings over the phone. The family physician tells the ob/gyn to proceed with any necessary treatment.

The patient is seen monthly for office evaluations that confirmed ovulation but failed to achieve conception. On April 25, diagnostic laparoscopy with chromotubation was performed with normal results. The decision was made to try menotropins therapy one week following surgery during an office encounter involving a postoperative check and one hour of face-to-face discussion of treatment options. At this encounter, the patient is instructed how to self-administer the menotropins and is given a supply of ampules, needles, syringes and alcohol wipes, and she watches a video on the preparation and administration of the drug. She calls the office as soon as her period starts two weeks later and she comes into the office the next day for an ultrasound to see if she is ready to start therapy. She is instructed to start the menotropins therapy three days later and is scheduled for daily blood work with the outpatient lab. The physician evaluates daily lab results to determine the amount of menotropins she should take each evening. The patient calls the office daily to get dosage instructions from the physician and to find out if an ultrasound will be required the next day. She has two office ultrasounds to check for follicles. These are performed on May 25 and May 30. The patients cycle lasts 11 days. On May 30, the [...]