Ob-Gyn Coding Alert

You shouldn’t assume pregnancy will be your primary diagnosis.

When a patient presents for an annual visit and is pregnant, you may find yourself wondering when to begin her global maternity care.

She may or may not know if she’s pregnant, but you should stick to one rule -- you must code what you know at the end of the visit.

Attack This Annual-Exam Scenario

Annual visits often lead to confusion when your ob-gyn establishes a patient’s pregnancy. You should choose from a range of different E/M codes according to three scenarios:

• a patient's annual visit leads to a diagnosis of her pregnancy
• she arrives knowing that she is pregnant
• the ob-gyn eliminates other possible diagnoses.

Scenario 1: Your ob-gyn diagnoses pregnancy during a patient’s annual exam. Can you still report the annual exam?

Solution 1: Yes, you can still report the annual exam. You need only link the pregnancy test result diagnosis to the diagnostic test and any significant E/M service that was documented in support of diagnosing pregnancy. Your claim should look like this:

• the annual exam (99384-99386 for new patients or 99394-99396 for established patients) linked to V72.31 (Routine gynecological examination)
• the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods) linked to V72.42 (Pregnancy examination or test, positive result).
• a low-level service (for example, 99212, Office or other outpatient visit, established patient, problem-focused history and examination, straightforward medical decision-making) with modifier 25 (Significant, separately identifiable evaluation and management service by same physician or qualified health care professional on the same day of the procedure or other service) linked to V72.42.

Don’t miss: Reporting the routine pregnancy codes V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy), or even V22.2 (Pregnant state, incidental), does not reflect the nature of the visit. Bottom line: The ob-gyn is not monitoring the pregnancy at this visit, and you have documented what you know at the end of the visit by using V72.42.

As for the ob record, you should not begin it until the next visit. Otherwise, carriers will consider the whole visit part of the global ob service.

Think of it this way: Physicians should not start the ob flow sheet or perform the comprehensive history, risk assessment or examination that is part of pregnancy care until after the first visit where the doctor confirmed the patient’s pregnancy. The next visit he schedules after the confirmation is the start of the global care.

Keep in mind: You must report what you know at the end of any visit. If the ob-gyn knows the patient is pregnant, you must report the patient as pregnant and include the appropriate pregnancy diagnosis. If you have a positive pregnancy test, that code will be V72.42.

What to Do When Patient Knows She’s Pregnant

Scenario 2: The patient comes in for her annual examination, already knowing she is pregnant. Can you still report the patient’s annual exam?

Solution 2: Yes — assuming your physician performed a preventive annual exam. If the only additional work is to re-confirm the pregnancy via a urine test, bill the diagnostic test in addition. If the physician instead only confirms pregnancy and does not perform the elements of a preventive exam, you should code the visit as a low-level service and a diagnostic test to confirm the pregnancy. In most cases, the physician will not have documented a separate significant E/M service in addition to a full preventive visit when the patient presents knowing she is pregnant.

Remember to link the pregnancy diagnosis to the test, not the annual examination. Your claim should look like this:

• If the annual is converted into a pregnancy confirmation visit, report a low-level service (for example, 99212, Office or other outpatient visit, established patient, problem-focused history and examination, straightforward medical decision-making) linked to the pregnancy exam diagnosis (V72.42).
• Report separately the diagnostic test (such as 81025) linked to the pregnancy exam diagnosis (V72.42).
• If only an annual exam is performed along with the urine test, report the annual exam code linked to V72.31 (Routine gynecological examination).

As for the global ob package, the patient should schedule a full visit with the ob-gyn after the annual exam. All visits, including the initial encounter with the physician, count toward the total for global care, which generally includes 13 outpatient antepartum visits.

Getting an ultrasound paid by any insurance company at the time the patient presents for an annual isn’t easy. Save yourself some hassle and set up a separate appointment for the ob-gyn to initiate the prenatal care, many payers are now considering evaluation of the pregnancy via ultrasound to represent starting the global ob package.

Attempt This No-Complaint Scenario

Scenario 3: The patient presents for her annual exam but has other complaints. The ob-gyn discovers the pregnancy. Can you still report the patient’s annual exam?

Solution 3: Yes. Actually, the work involved in eliminating other possible diagnoses may constitute a higher-level E/M service. That work would not focus on or relate to the pregnancy, except to confirm it with a test.

Your claim should look like this:

• the higher-level E/M service (such as 99214, Office or other outpatient visit for an established patient ... 25 minutes face-to-face) with modifier 25 added and linked to the diagnosis for the problems evaluated
• the diagnostic test (such as 81025) linked to V72.42
• the annual exam code linked to V72.31.

ICD-10: When your diagnosis code system changes, you’ll have new options for those codes mentioned in this article:

• Code V72.42 becomes Z32.01 (Encounter for pregnancy test, result positive)
• Code V72.31 becomes Z01.411 (Encounter for gynecological examination [genera] [routine] with abnormal findings) or Z01.419 (Encounter for gynecological examination [genera] [routine] without abnormal findings).
• Code V22.0 expands into four options: Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.04 (... third trimester).
• Code V22.1 will include the four new codes listed above as well as four more: Z34.80 (Encounter for supervision of other normal pregnancy, unspecified trimester), Z34.81 (... first trimester), Z34.82 (... second trimester), and Z34.83 (... third trimester).
• Code V22.2 will become Z33.1 (Pregnancy state, incidental).