Wiki initial OB Visit

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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
 
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)
 
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?
 
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
 
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
 
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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