Wiki How is this should be coded? (OB/GYN OUTPATIENT)

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anmareza

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Hi guys!

Can you please help me to code this ob encounter?

Scenario:
An established patient visited the clinic for her initial antenatal care. She is currently 15 weeks pregnant (G2,P1) with previous cesarean section due to breech presentation. This is a spontaneous pregnancy. Patient has currently no complaints. No nausea, no vomiting, no abdominal pain, no vaginal bleeding. She is a known case of Uterine Fibroid, and Iron Deficiency Anemia. Patient is taking oral iron replacement. No surgical history, negative family history. The physician requested dating scan and booking investigation for the patient.

I hope you can help me with this.

Thank you!!!
:):)
 
This is pretty straight forward encounter. It is a prenatal visit so it is a global OB code for the visit level we use 0500F for initial. The dx codes will come from the O chapter you will find one for pregnancy with previous c-section and if therovoder documents the anemia and the uterine fibroids you will find O codes for these as well. It is also important to note the age of the patient to determine if she is a young or elderly gravida. Take a stab at and see what you come up with
 
mitchellde said:
This is pretty straight forward encounter. It is a prenatal visit so it is a global OB code for the visit level we use 0500F for initial. The dx codes will come from the O chapter you will find one for pregnancy with previous c-section and if therovoder documents the anemia and the uterine fibroids you will find O codes for these as well. It is also important to note the age of the patient to determine if she is a young or elderly gravida. Take a stab at and see what you come up with
Click to expand...

Is it correct to give e/m level of 99214 to this encounter?
 
not related, need help

Good Day,

I want to ask regarding one of the cases of our pt. She is 57 Years Old, She's having Spastic quadriparesis. I found the code for this is G80.0 - Spastic quadriplegic cerebral palsy. However, she doesn't have cerebral palsy. Which code (ICD 10) should i use for this diagnosis? Thanks in advance!
 
iamkimatienza said:
Good Day,

I want to ask regarding one of the cases of our pt. She is 57 Years Old, She's having Spastic quadriparesis. I found the code for this is G80.0 - Spastic quadriplegic cerebral palsy. However, she doesn't have cerebral palsy. Which code (ICD 10) should i use for this diagnosis? Thanks in advance!
Click to expand...

I would need to look at the documentation, newly diagnosed in a 57 year old this would not be CP so the question is what is the paralysis related to. Was there some type of stroke or anoxic brain injury documented? Do not use G80.0 for this patient. Look carefully in the documentation there is sure to be additional information that will lead to the appropriate code.
 
You bill OB as a global charge after delivery. We track the prenatal visits using 0500F for the initial and 0502F for the subsequent visits. As far as I know this is how most do it unless the payer such as Medicaid in some sites wants it billed for each encounter
 
mitchellde said:
You bill OB as a global charge after delivery. We track the prenatal visits using 0500F for the initial and 0502F for the subsequent visits. As far as I know this is how most do it unless the payer such as Medicaid in some sites wants it billed for each encounter
Click to expand...

Our payer is billing separately for each visit.
 
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