Ob Patient in Hospital - But Not for Delivery Question


San Francisco, CA
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I have a client who is looking for a guide to an OB physical examination for hospital E&M services for patients that are not in the hospital for delivery - the regular ob-gyn focuses mostly on gynecological exam and the physicians are having difficulty getting a high enough PE to support a higher code that would support the high complexity of medical decision making - any help?

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Without more information, it is hard to answer this question. Is the patient in the hospital for something unrelated to the pregnancy? Is there a complication of the pregnancy? Is this an inpatient stay? Is this an admit or subsequent visit? I am assuming from your question that there is enough documentation in MDM to support the higher code, you just don't have enough HPI and/or exam.

Documenting time based counseling is one option if the visit was predominantly counseling, although I don't see this often in a hospital setting.

You could also look at single system exam requirements under the 97 guidelines. (This may be your best bet in this scenario).

Hope this helps some.

Hi Amy,
Thanks for your reply. In speaking further with the coder, we decided that she should use the 95 guidelines for the admits that are sort of related to pregnancy - i.e., diabetes - high risk to mother and child, so treat admit like any other not primarily obstetrical.
i agree with carol, 95 guidelines is the way to go. my docs and i (since i get to review and audit the charges)found it very difficult to meet the 97 exam requirements for obgyn specific exams.
8+ organ systems (95) was alot easier for them to document.
now to reach a high level of MDM is not an easy task and i very rarely see in in obgyn.not that htis helps you much
now of course with initial hospital (99218-99223) it must meet all 3 elements (just like a new pateint)
i do have refernce sheets available if you wish you can email me at bigredcag@hotmail.com and i will be happy to send them to you(the file is too bil for me to attach to htese threads)
1 is 97 obgyn specific and the other is the 95 guidlines
they will be in microsoft excell
hope this info helps
christine G. CPC