Ob-Gyn Coding Alert

You Be the Coder:

Pregnancy Confirmation

Question: Can a provider bill a separate evaluation and management (E/M) service for confirmation of pregnancy, or is it considered to be initial OB? Patient saw her primary care physician (PCP) via telemedicine prior who diagnosed amenorrhea with positive home pregnancy test and referred to follow up with OB to continue with prenatal vitamins. In this situation, the PCP didn’t order a test to confirm pregnancy besides the patient doing a home test. Just the referral to OB.

I want to make sure the OB provider can bill an E/M and not consider this visit the initial OB. I have read where it states if OB started the prenatal record, then this would be considered the initial OB. How would I know that?

Here is the visit:

31 y.o.-year-old female presents for confirmation of pregnancy. She has irregular menses. LNMP was on 1/3/21? Denies hematuria or hematochezia. Denies bowel and bladder changes.

Ob/gyn hx: G1

Physical exam:

The patient declines nurse presence for examination

Blood pressure 143/82, pulse 118, height 5’ 2” (1.575 m), weight 156 lb (70.8 kg), last menstrual period 01/03/2021.

General: alert and oriented and in no acute distress

Abdomen: soft nontender to palpation, positive bowel sounds. No hernia

Pelvic Exam: Deferred PSYCHIATRIC: alert and oriented to time, place and person UCG+

Obstetrical Ultrasound: Single IUP with AUA consistent with 6-7 weeks. Positive cardiac motion. Measurements sub-optimal on abdominal scan, she declines vaginal scan

Assessment: 1. Amenorrhea: Prenatal Profile I, UA/M w/rflx Culture, Routine, HIV 1/0/2 Antigen/AB 4th Generation

2. early pregnancy at 6-7 weeks

PLAN: Prenatal lab panel, PAP and genital cultures

Start prenatal vitamins

I spent 30 minutes reviewing the patient’s diagnostic tests, labs, examining the patient, counseling the patient, reviewing the treatment options/plan and documenting in the medical record.

What should I report?

Connecticut Subscriber

Answer: In this situation, this physician is evaluating the pregnancy, not simply confirming she is pregnant. You know this because he did an ultrasound to evaluate the fetus and also because she was counseled regarding treatment options, which would of course be related to pregnancy care — even though the ob-gyn did not document the exact content of the conversation.

The basic confirmation of pregnancy visit is a low-level visit (99211, Office or other outpatient visit …) with a urinalysis (UA) pregnancy test (81025, Urine pregnancy test, by visual color comparison methods). Then you can order labs but stop there.

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