Wiki Billing an E&M with a routine OB visit

[CRHanson]

Is an E&M is appropriate to bill when this patient came in for a routine OB check up and has a problem. I have been looking at ACOG guidelines and struggling to find firm information on if an E&M is warranted. The argument is that the BV was a complication of the pregnancy and a prescription was ordered. The opposing view is that it was a scheduled, routine OB visit and is a complication of the pregnancy and should be included in the global package.



"Patient is doing well today. She is doing her glucose testing and hemoglobin test today. She is having some round ligament pain. No contractions, bleeding, or fluid leaking. She is also complaining of some greenish discharge that is irritating. We will send a prescription for MetroGel for presumed bacterial vaginosis. Intercourse is also uncomfortable. We will plan to see her back in 1 month again."

 

[mitchellde]

It is a complication and is part of global you use the O23.59-adding th digit for the trimester. You do not add the N76.0 code and code it as you do for prenatal visit we use the 0502F

 

[CRHanson]

I agree that it should be considered part of the global ob. The problem is that according to ACOG it states that a complication of pregnancy could be concerned service outside the global package which is where. I’m having trouble finding firm documentation to back my thoughts that this visit should all be part of the global visit.

 

[mitchellde]

If your documentation can support that the patient presented for the purpose of the vaginitis and the provider focused on that problem as well as checking the baby, then you can code it as an office visit level, many payers will have you use the 24 modifier to show it is a service provided outside of global.