E/M Visit Auditing Ob Visits Help!

espforu

Guru
Local Chapter Officer
Messages
140
Location
NAPLES, FL
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I am trying to audit our Ob visits(we do not do the delivery and bill out per visit mostly Medicaid patients or self pay).

I have a reference from a conference the CMO went to and it indicates that most Ob visits are generally a level 3 visit(based on documentation).
History
Brief HPI-Quality(gestational age)
ROS-1(e.g inquiring about nausea,vomiting, cramps or spoting)
PFSH-0

EXAM
V.S.-(Constitutional)
Checking for edema(Cardio)
Uterus-fundal height(GU)
Cervix(GU)
Fetal heart rate(Cardio)
Fetal Movement(Musculosketal)

MDM
Routine-Low Complexity

I am trying to understand how the fetal movement is in the Musculoskeltal? or MDM considered low?

Does anyone have any audit reference for OB they can share? Myself and the CMO are a little lost on this.

Thank you so much!
 

ajs

True Blue
Local Chapter Officer
Messages
1,087
Location
Tacoma, WA
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I am trying to audit our Ob visits(we do not do the delivery and bill out per visit mostly Medicaid patients or self pay).

I have a reference from a conference the CMO went to and it indicates that most Ob visits are generally a level 3 visit(based on documentation).
History
Brief HPI-Quality(gestational age)
ROS-1(e.g inquiring about nausea,vomiting, cramps or spoting)
PFSH-0

EXAM
V.S.-(Constitutional)
Checking for edema(Cardio)
Uterus-fundal height(GU)
Cervix(GU)
Fetal heart rate(Cardio)
Fetal Movement(Musculosketal)

MDM
Routine-Low Complexity

I am trying to understand how the fetal movement is in the Musculoskeltal? or MDM considered low?

Does anyone have any audit reference for OB they can share? Myself and the CMO are a little lost on this.

Thank you so much!
That is difficult because OB visits are not the same as other standard E/M visits. Any documentation related to the fetus, counts toward the fetus not the mom. There are two patients being evaluated at each visit, the mom and the fetus. Most OB visits meet more of a level 4 than a level 3 because of the risk involved.
 

espforu

Guru
Local Chapter Officer
Messages
140
Location
NAPLES, FL
Best answers
0
Thanks so much,

Do you have any references you can refer me too? One conference is indicating otherwise. I want to make sure I am auditing these correctly.
 
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