Ob-Gyn Coding Alert

Hint: You should wait until the next full visit in most circumstances.

So your ob-gyn discovers a patient is pregnant during her annual visit. Do you know what to do? The answer depends on the method the ob-gyn used, but of course, the challenge doesn’t end there. You have to decide what clinical diagnosis to use.

Rule of thumb: In the majority of circumstances, you should not begin counting antepartum visits for the global maternity codes (59400, 59510, 59610, 59618) until the next full visit, coding experts say.

Solve the Pregnancy Diagnosed During Annual Exam Problem

As you’re probably aware, annual visits often lead to confusion when it comes to establishing a patient’s pregnancy. So do you know how to handle these situations?

You should choose from a range of different E/M codes according to three scenarios:

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

Scenario 1: If the ob-gyn diagnoses pregnancy (Z32.01, Encounter for pregnancy test, result positive) during a patient’s annual exam (99384-99386 for new patients, or 99394-99396 for established patients), you can still report the annual examination, as long as you link the pregnancy diagnosis to the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods).

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

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 pregnancy diagnosis Z32.01. You do not begin reporting Z34.0 (Encounter for supervision of normal first pregnancy …), Z34.8- (Encounter for supervision of other normal pregnancy …), or Z33.1 (Pregnancy state, incidental) until your physician has begun to supervise the pregnancy.

Scenario 2: The patient comes in for her annual examination, already knowing she is pregnant. You should code the visit as a low-level service (for example, 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history …) to confirm her pregnancy (such as 81025). Remember to link the diagnosis (V72.42) to the test and the visit code.

After this visit, the patient will schedule a full visit with the ob-gyn. The global care would begin at this first visit. All visits, including the initial encounter with the physician, count toward the total for global care, which generally includes 13 outpatient antepartum visits.

Scenario 3: If the patient presents for her annual exam but has other complaints, and the ob-gyn then discovers pregnancy, the work involved in eliminating other possible diagnoses may constitute a higher-level E/M service (such as 99214, Office or other outpatient visit for… an established patient ... 25 minutes face-to-face…) instead of the annual exam, or an annual exam with a problem E/M service if appropriately documented.

That work would not focus on or relate to the pregnancy, except to confirm it with a test (like 81025). Therefore, if the ob-gyn makes other diagnoses in addition to the pregnancy, you should include them as relevant to the E/M service, with Z32.01 supporting the need for the pregnancy test.

How to Code Pregnancy Diagnosed During Nonscheduled Visit

Similar rules apply when the patient sees her ob-gyn for a nonannual examination visit.

Scenario 1: The patient sees her ob-gyn for abdominal cramping, sweating, having missed a period, or for other possible symptoms. These complaints prompt the ob-gyn to order a pregnancy test (like 81025). He learns from the results that she is pregnant.

You should report an E/M service because the symptoms are related to a problem that turned out to be pregnancy. If the ob-gyn evaluated other possible problems (which eventually revealed the pregnancy), you should report this service outside the global ob package.

You should still report the pregnancy code (Z32.01) by attaching it to the lab test for pregnancy, but make sure the claim clearly details how the ob-gyn did not see the patient for pregnancy but for other symptoms.

Scenario 2: If the patient comes in with complaints and thinks she might be pregnant, the ob-gyn will determine whether these complaints relate to the pregnancy.

If these complaints do relate to her being pregnant, you should code the service as part of the global ob package (if the ob-gyn initiated the record during this visit). If the chief complaint of the patient, or in other words, the signs and symptoms, were because the patient is pregnant, then the ob record would begin. If your ob-gyn initiates the ob record during that visit, the entire visit becomes part of the global period.

Scenario 3: The same patient arrives knowing that she is pregnant because her home pregnancy test was positive.

If the ob-gyn simply “confirmed the confirmation,” you should code by the method used to confirm the pregnancy. This method might include either the urine pregnancy test (81025) if the ob-gyn performed one, or a low-level E/M service if some discussion with the patient took place.

Note: Many practices do not accept home pregnancy tests and require a test from the patient’s primary-care physician or other medical source.

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