Wiki OB Physical exam

[BPalumbo1129]

Good morning,

I hope what I am asking makes sense..

Our providers are asking if a comprehensive physical exam has to be documented and billed as a New OB visit or can it be in theory billed as a gynecological visit early in the pregnancy. What I have read and to my understanding is the comprehensive physical exam is to be done when the patient comes in for her initial OB appointment (OB record initiated) as the comprehensive physical exam is part of the global OB package. The confirmatory of pregnancy visit does not include a comprehensive physical exam. Our providers are thinking that the comprehensive physical exam can be done at some point around entry to obstetrical care, the rationale being that their general physical exam has been performed and a clinical pelvic exam has been performed as a baseline at entry to care.

I appreciate any feedback and thoughts about this matter.

Thank you!

 

[natashalage]

Hello, I am not an expert and do not have a big experience with comprehensive physical exam but I know that Confirmation of pregnancy can be billed as a separate E/M with Z code- pregnancy positive. Confirmation of pregnancy billing was broadly discussed in this Forum. I suggest to use Search option to pull more information and we hope that our experts will respond to your question soon. I will learn too. Great question!

 

[nielynco]

Good morning,

I hope what I am asking makes sense..

Our providers are asking if a comprehensive physical exam has to be documented and billed as a New OB visit or can it be in theory billed as a gynecological visit early in the pregnancy. What I have read and to my understanding is the comprehensive physical exam is to be done when the patient comes in for her initial OB appointment (OB record initiated) as the comprehensive physical exam is part of the global OB package. The confirmatory of pregnancy visit does not include a comprehensive physical exam. Our providers are thinking that the comprehensive physical exam can be done at some point around entry to obstetrical care, the rationale being that their general physical exam has been performed and a clinical pelvic exam has been performed as a baseline at entry to care.

I appreciate any feedback and thoughts about this matter.

Thank you!

If the purpose of seeing the patient is obstetric care, the comprehensive exam is always included. This can be done at the first visit the patient is seen or a second visit - especially if the purpose of the first visit is ONLY to confirm pregnancy - a complete gyn exam is not medically indicated for confirmation of pregnancy, but would be part of global care. We have presented many different articles in the OB/GYN Coding Alert of this topic which outline the various scenarios when the patient's exam can be counted as something other than an OB exam. The initial exam is considered the baseline exam by almost all payers out there. So if your providers insist on billing this make darn sure your documentation clearly indicated by the "baseline" comprehensive exam was medically indicated outside of OB care.