Ob-Gyn Coding Alert


Bust 3 Myths to Bolster Your Pregnant Patient Annual Exam Claims

Hint: Here’s why you need to be careful what you use for your primary dx.

To ethically maximize your ob-gyn practice’s bottom line, you need to know the difference between reporting an annual exam code versus beginning global maternal care. Bust these three myths to clarify what you should do.

Hint: The starting line for global maternal care isn’t always clear-cut when a patient presents for an annual visit. At the beginning of the visit, she may or may not know she’s pregnant, but you should stick to one rule: you must code what you know at the end of the visit.

Myth #1: Your ob-gyn diagnoses pregnancy during a patient’s annual exam—which means you have to throw the annual exam codes out the window.

Reality: Actually, you can still report the annual exam. You need only link the pregnancy test result diagnosis to the diagnostic test, points out Peggy Stilley, CPC, CPC-I, CPMA, CPB, COGBC, Senior Education Specialist for the AAPC.

Your claim should look like this:

  • the annual exam (99384-99386 for new patients, or 99394-99396 for established patients) linked to Z01.411 (Encounter for gynecological examination [general] [routine] with abnormal findings) or Z01.419 (... without abnormal findings).
  • the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods) linked to Z32.01 (Encounter for pregnancy test, result positive).

Choose from the routine pregnancy codes Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester), Z34.01 (... first trimester), Z34.02 (... second trimester), Z34.04 (... third trimester), Z34.90 (Encounter for supervision of normal pregnancy, unspecified, unspecified trimester), Z34.91 (... first trimester), Z34.92 (... second trimester), Z34.93 (... third trimester), or Z33.1 (Pregnancy state, incidental).

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 Z32.01. 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: Tell your doctors to not start the ob flow sheet until after the first visit where the doctor confirmed the patient’s pregnancy. The next visit the ob schedules after the confirmation is the start of the ob flow sheet. This prevents visits where patients come in to start prenatal care, only to find out they are not pregnant.

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 Z32.01.

Myth #2: Patient comes in for her annual exam already knowing she’s pregnant. Reporting the annual exam is a no-no.

Reality: You should code the annual visit and a diagnostic test to confirm the pregnancy. The annual visit is what the patient was coming in for.

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

  • the diagnostic test (such as 81025) linked to the pregnancy exam diagnosis (Z32.01)
  • the annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) linked to Z01.411 or Z01.419.

Caution: You would not normally also bill for a low level service (such as 99211) under this circumstance unless there was a significant and separate E/M service related to the pregnancy evaluation at this annual visit. In most cases, the physician will merely confirm the home pregnancy test and schedule the patient for obstetric care at the next visit. But keep in mind that if the pregnancy is being evaluated or managed, the payer is likely to include the entire visit as part of global care.

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

Getting a confirmatory ob ultrasound paid by any insurance company at the time the patient presents for an annual isn’t easy. Experts advise you to save yourself some hassle and set up a separate appointment for the ob-gyn to initiate the prenatal care.

Myth #3: The patient presents for her annual exam but has other complaints, and the ob-gyn discovers she is pregnant. You shouldn’t therefore not report the annual exam.

Reality: 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 the evaluation and management of an established patient ... 25 minutes face-to-face…) with 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) added and linked to the diagnosis for the problems evaluated
  • the diagnostic test (such as 81025) linked to Z32.01
  • the annual exam code (99384-99386 for new patients, or 99394-99396 for established patients) linked to Z01.411 or Z01.419.

But remember that you cannot double count things you use to determine the unrelated level of service with the things you are counting toward the annual exam. The two services must be clearly separate, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.