Ob-Gyn Coding Alert

Question: How should I code a patient who came in for a pregnancy test when the test was positive but we did not start the ob record? Can I use V72.40?

New Mexico Subscriber

Answer: You cannot use V72.40 (Pregnancy examination or test, pregnancy unconfirmed) if the ob-gyn knows the patient is pregnant at the end of the visit. The "unconfirmed" term in the descriptor means that you do not know whether she is or not, but in this case, you do.

Second, if you know she is pregnant at the end of the visit, ICD-9 guidelines state that you must put that information on the claim, using V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) regardless of whether or not you start the ob record.

You may want to use this diagnosis on the lab test the ob-gyn performs to verify pregnancy and attribute the symptom code to the E/M service. That way, you have covered the reason for your visit as well as your finding, but you indicate that you are not starting the ob care just yet.