Revenue Cycle Insider

Question: An established 28-week pregnant patient presented to their regular ob-gyn office for an unscheduled visit reporting severe right lower quadrant (RLQ) abdominal pain. The ob-gyn performed a detailed evaluation, diagnosed suspected acute appendicitis, and coordinated an immediate transfer to the inpatient surgical unit, where a general surgeon performed an appendectomy later that evening. The ob-gyn also performed an obstetrical ultrasound in the office to confirm fetal well-being before transfer.

How should we report the ob-gyn’s services?

Louisiana Subscriber

Answer: Assign an appropriate office evaluation and management (E/M) service code, such as 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.), and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Since the patient presented with an acute condition requiring distinct medical decision making prior to surgical intervention by a separate specialist, the office E/M code is fully reimbursable. The limited ultrasound is a diagnostic imaging service that is explicitly separately reportable from the E/M encounter. Use 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses) to report the ultrasound procedure.

Aniket Sanjay Bagate, CPC, CEMC, Pune, Maharashtra, India