Wiki Required NST Documentation - 59025

[tloeb]

Can anyone weigh in on whether a NST 59025 is billable when the documented components of the NST are comingled within the E/M documentation? Or does the NST need to be documented separately either as a procedure note or within the E/M notes as a separtely titled procedure with detail/results? Example of comingled within the E/M that ACOG is stating not billable is below NST in bold:
Objective

Vitals:
	09/09/23 1839	09/09/23 1850	09/09/23 1859	09/09/23 1909
BP:	144/82	136/70	131/72	136/72
Pulse:	111	103	102	100
Resp:
Temp:

Gen: AO x 3, NAD
CV: RRR
Resp: CTAB
Skin: warm and dry to touch, no rashes
Abdomen: Gravid, soft, NT to palpation
Back: neg CVAT
Extremities: warm and well perfused, 1+ pitting edema in upper extremities, 2+ pitting edema in lower extremities, DTRs 1+ bilateral LE
SVE: deferred
FHTs: Baseline 150, moderate variability, + accelerations, no decels.
UCs: q 5-10min, mild to palpation
Labs: PIH pannel sent.
GBS/GBS rapid sent

Assessment
XXXXXXXX is a _29 y.o._ G1P0 at 35w3d
Does not meet gestational HTN diagnosis because we do not have recorded HTN BPs greater than 4 hours apart.
VSS
Reactive NST
Vertex confirmed via BS US.
GBS Pending

Thank you!

 

[Cmama12]

I don't have any resources to direct you to but I can tell you that we often see them embedded and we do bill them out separately. Here's one I just came across

Physical Exam:
General appearance: alert, appears stated age, cooperative and in no apparent distress
Head: Normocephalic, without obvious abnormality, atraumatic
Skin: No lesions, bruising or abnormal skin discoloration apparent
Lungs: normal effort
Heart: normal rate
Abdomen: Soft, non tender, gravid, pain with palpation of paraspinal muscles on the left consistent with musculoskeletal origin, no CVA tenderness. No RUQ pain.
Extremities: no clubbing, no cyanosis, trace non pitting edema, redness or tenderness in the calves
Psych: Appropriate mood and affect
GU: deferred

Reactive NST with Baby A baseline at 135, moderate variability, with accels and Baby B baseline at 135, moderate variability, accels. Irregular contractions on toco.

 

[rtrudel35]

As long as the documentation was done by a doctor or CNM then we would bill for a NST with that documentation. Alot of the time the NST is done by a RN but we need a provider to write an attestation or their own interpretation.

 

[Jenetteis]

Hi, is this acceptable to bill as an NST? TIA

FHR reactive
Uterine activity is being monitored by TOCO with contractions occurring Irregular minimal