Ob-Gyn Coding Alert

Ob/gyn coders: There are rules for correct coding and optimal reimbursement that you can and should follow, regardless of carrier or patient circumstances. At a recent pediatric and ob/gyn coding and compliance conference sponsored by The Coding Institute, experts offered the following pointers for successfully coding women's health services: Tip #1: Document height, weight and blood pressure. In doing so, the physician documents the constitutional system as part of the examination. Or the review of the information can be used to document the portion of history that entails the review of systems (ROS), according to Philip Eskew Jr., MD, medical director of infant and women's services at St. Vincent's Hospital in Indianapolis.

A review of the patient's height represents a review of the musculoskeletal system, blood pressure indicates a review of the cardiovascular system, and weight a review of the constitutional system, Eskew says. Not only do these vital signs help the physician pinpoint possible problems, but they can be taken by the nurse and recorded in the chart for the physician to review. The physician can discuss any unusual weight gain or loss, changes in blood pressure, or loss of height (associated with osteoporosis) with the patient during the face-to-face encounter, he adds. Tip #2: Make the physician choose the E/M and ICD-9 codes for the visit. Coders shouldn't be stuck second-guessing their physicians as to what care was rendered and what diagnoses determined the need for the service, according to Eskew. With E/M visits, a coder or practice staff member could easily downcode or upcode a visit, resulting in lost revenue or skewed statistics of higher-level visits. An incorrect diagnosis code can result in denial of payment for a number of reasons. The carrier might not pay for the indicated diagnosis, or treatment might not match the carrier's list of linked diagnoses, Eskew says. Rather than determining the physician's intent based on chart notes, practice and coding managers should work with their physicians to instill the importance of doing their own coding. The alternative is lost revenue and possibly even an audit or allegations of fraud, he warns. Tip #3: Don't confuse consultations with referrals. Coders and physicians should not use the "R" word when seeing a patient on a consultative basis, advises Harry L. Stuber, MD, an independent gynecologist based in Cookeville, Tenn. In other words, the chart note should not read, "Patient A was referred by Dr. B for evaluation and management of ... ", Stuber explains. Instead, the physician might indicate that "Dr. B has sent patient A for consultation regarding the evaluation and management of... " The term "referral" implies that a transfer of care has taken place and the referring physician is essentially [...]