initial OB Visit

kbarron

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Are you allowed to bill the first visit with the MD to establish the Prenatal record? I am very rusty from not coding OB. Thanks in advance
 
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We code our 1st visit as "confirmation" of pregnancy. The patient presents with a missed period ( E&M, 626.8), is given an "GYN" ultra sound to confirm the pregnancy (76856, 626.8, V72.42) as long as you DO NOT start the prenatal record until the following visit. ACOG has a great article on this written about 2 years ago. If you want me to fax you a copy, email me at andersonj@wcpdx.com. Jamie (I may not check back soon enough on this forum)
 

caroline

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I'm currently reviewing our EM coding from our OB/GYN and it seems that they are billing either EM level 4 & 5 for "confirmation " of pregancy and the documentation dosen't support it? Are your OB doc's billing high levels for these type of visits?
 
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Milwaukee WI
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Documentation is key

Caroline, you write ... they are billing either EM level 4 & 5 for "confirmation " of pregancy and the documentation dosen't support it

The cardinal rule of billing is: Doctor should document what s/he does. Coder should code what is documented.

If documentation doesn't support the levels that are being marked by the physicians then I suggest an internal audit and education. And, yes, give back the money that was received for services that were coded higher than documented.

F Tessa Bartels, CPC, CPC-E/M
 

caroline

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Tessa,

Thanks for your response. I noticed your EM certified as well, so I have another question relating to the same scenario.

The patient is fine w/ no other findings only pregnancy confirm, thats what was documented:
A. New problem w/additional w/u
B. Low (acute uncomplicated illness)
C. 2 point (labs & ultrasound)

Would you agree that it's a low risk? I'm meeting with all the OB doc's tomorrow since this seems to be a pattern with billing confirm pregnancies.
Thanks,
Caroline
 
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Based on the information you provided

Based solely on the information you provided ...
... what was documented:
A. New problem w/additional w/u
B. Low (acute uncomplicated illness)
C. 2 point (labs & ultrasound)


I'd agree that this MDM is LOW complexity. So, depending on the rest of the documentation (history and exam) the most you could get would be 99203 if it's a new patient, or 99213 if it's an established patient and MDM is one of the two components on which you base the level of service.

F Tessa Bartels, CPC, CEMC
 
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