Good news: You can report a higher-level (and higher-paying) E/M in this annual-visit situation.
Annual visits often lead to confusion when it comes to establishing a patient’s pregnancy. Take this 3-part challenge by deciding if the ob-gyn package begins based on these scenarios:
• a patient’s annual visit leads to a diagnosis of her pregnancy,
• she arrives knowing that she is pregnant, or
• the ob-gyn eliminates other possible diagnoses.
Hint: In the majority of circumstances, you should not begin counting antepartum visits for the global maternity codes (59400, 59510, 59610, 59618) until the next full visit, coding experts say.
Still Report Annual When Visit Leads to Pregnancy Dx
Scenario 1: If the ob-gyn diagnoses pregnancy (V72.42, Pregnancy examination or test, positive result) during a patient’s annual exam (99384-99386 for new patients, or 99394-99396 for established patients), you can still report the annual examination, as long as you link the pregnancy diagnosis to the diagnostic test (for instance, 81025, Urine pregnancy test, by visual color comparison methods).
Trap: You should not report codes V22.0 (Supervision of normal first pregnancy), V22.1 (Supervision of other normal pregnancy), or V22.2 (Pregnant state, incidental) because these codes imply your ob-gyn has begun supervising the pregnancy.
Rule: You must report what you know at the end of any visit. If the ob-gyn knows the patient is pregnant, you must report the patient as pregnant. Code V72.42 suffices because the pregnancy care has not begun. You will also report v72.31 (Routine gynecological examination) in support of the annual exam.
Does global ob package start? No. You should not begin the ob record until the next visit. Otherwise, carriers will consider the whole visit part of the global ob service.
Pregnancy Confirmation Means a Code Like 99212
Scenario 2: The patient schedules her annual examination but already knows she...
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