Ob-Gyn Coding Alert

Question: My ob-gyn saw a patient for a routine ob visit at 11 weeks 3 days GA. In the history portion, he notes that she is experiencing some nausea. She takes Unisom, which seems to help with the nausea. Otherwise, the patient is fine (no dizziness, no other complaints, feels well), and the exam is normal. The ob-gyn does note that she has a low blood pressure at 90/60, but he qualifies this as a normal pregnancy visit.

We're wondering if we should code this as a complication, because the patient has nausea and is taking Unisom. Do we have any complication diagnosis? The ob-gyn does not state the nausea was affecting the pregnancy. How about the low blood pressure?

Tennessee Subscriber

Answer: You should examine the ob-gyn's notes. Ask, did the ob-gyn provide routine ob care, or did the ob-gyn do something to manage the patient's complaint or serious finding?

Most pregnant women have nausea and yes, vomiting with pregnancy. Only some patients require treatment initiated by the physician (such as, IVs for dehydration, prescription drugs, lab tests, and so on). The same goes for blood pressure. Unless the physician is changing routine care due to this finding, you should consider this a normal visit--not a condition that is complicating the management of the mother during pregnancy.