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E/M Visit Auditing Ob Visits Help!

  1. #1
    Location
    Naples Florida
    Posts
    140
    Question E/M Visit Auditing Ob Visits Help!
    Medical Coding Books
    I am trying to audit our Ob visits(we do not do the delivery and bill out per visit mostly Medicaid patients or self pay).

    I have a reference from a conference the CMO went to and it indicates that most Ob visits are generally a level 3 visit(based on documentation).
    History
    Brief HPI-Quality(gestational age)
    ROS-1(e.g inquiring about nausea,vomiting, cramps or spoting)
    PFSH-0

    EXAM
    V.S.-(Constitutional)
    Checking for edema(Cardio)
    Uterus-fundal height(GU)
    Cervix(GU)
    Fetal heart rate(Cardio)
    Fetal Movement(Musculosketal)

    MDM
    Routine-Low Complexity

    I am trying to understand how the fetal movement is in the Musculoskeltal? or MDM considered low?

    Does anyone have any audit reference for OB they can share? Myself and the CMO are a little lost on this.

    Thank you so much!

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by espforu View Post
    I am trying to audit our Ob visits(we do not do the delivery and bill out per visit mostly Medicaid patients or self pay).

    I have a reference from a conference the CMO went to and it indicates that most Ob visits are generally a level 3 visit(based on documentation).
    History
    Brief HPI-Quality(gestational age)
    ROS-1(e.g inquiring about nausea,vomiting, cramps or spoting)
    PFSH-0

    EXAM
    V.S.-(Constitutional)
    Checking for edema(Cardio)
    Uterus-fundal height(GU)
    Cervix(GU)
    Fetal heart rate(Cardio)
    Fetal Movement(Musculosketal)

    MDM
    Routine-Low Complexity

    I am trying to understand how the fetal movement is in the Musculoskeltal? or MDM considered low?

    Does anyone have any audit reference for OB they can share? Myself and the CMO are a little lost on this.

    Thank you so much!
    That is difficult because OB visits are not the same as other standard E/M visits. Any documentation related to the fetus, counts toward the fetus not the mom. There are two patients being evaluated at each visit, the mom and the fetus. Most OB visits meet more of a level 4 than a level 3 because of the risk involved.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Location
    Naples Florida
    Posts
    140
    Red face
    Thanks so much,

    Do you have any references you can refer me too? One conference is indicating otherwise. I want to make sure I am auditing these correctly.

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