Ob-Gyn Coding Alert

In the chapter notes preceding the codes, CPT indicates that uncomplicated maternity cases include such services as "initial and subsequent history, physical examinations, recording of weight, blood pressure, fetal heart tones, routine chemical urinalysis, monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation and weekly visits until delivery."

Despite CPT's description of included services, there is confusion about how to code the initial ob visit, says Michele Creswell, LPN, CPC, billing manager for the department of obstetrics and gynecology at the University of Nebraska Medical Center in Omaha. "I wonder how many practices are billing for the first ob visit and what diagnosis code they're using," she asks.

The answer depends on when pregnancy is established. At the outset of global ob care, most physicians require a reliable pregnancy test prior to setting up the initial visit, which is usually in-depth and lasts about 40 minutes. This is the start, or the first visit, of the ob global package.

But many practices do not accept home pregnancy tests and require a test from the patient's primary care physician or another medical source.

So, if the patient does not have reliable pregnancy-test results from another physician or clinic, many practices schedule an initial visit just for administering a pregnancy test, usually by urinalysis (81025, Urine pregnancy test, by visual color comparison methods).

At this visit, the patient reports to the office and gives a urine sample. When the pregnancy is confirmed, the patient schedules a full visit with the physician, initiating her global care. All visits, including the initial encounter with the physician, are counted toward the total for global ob care, which is generally accepted as including 13 outpatient antepartum visits.

If the patient presents with a positive home pregnancy test in other words, knowing she is pregnant and the physician initiates the ob record at that visit, the American College of Obstetricians and Gynecologists considers this the first global visit, whether or not the physician requests a second confirmation of pregnancy. The exception to this is when the patient reports not knowing she is pregnant, and the pregnancy is diagnosed at that visit.

If the pregnancy is not confirmed when the patient walks in the door, then the visit becomes a gynecological appointment coded with 626.8 (Missed period).

Coders are often tempted to use the code for amenorrhea, 626.0 (Absence of menstruation), but this is appropriate only for patients who have not had a period for six months or who have had very irregular periods and not menstruated for the last three months.

This visit would probably be documented and coded as a low level E/M service (e.g., 99202, Office or other outpatient visit for the evaluation and management of a new patient).