Wiki Ob Patient in Hospital - But Not for Delivery Question

[Yarbs]

Hello,

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?

Thanks!
Carol

 

[donsqueen]

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.

Amy

 

[Yarbs]

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.
Thanks!
Carol

 

[bigredcag]

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