OB Coding – The Global Package & Beyond
OB Coding ? The Global Package & Beyond
Kerin Draak, MS, WHNP-BC, CPC, CEMC COBGC kerind@
You Will Learn
? How to code for routine pregnancy services ? What services are billable outside the OB global
package ? How documentation is required to look
to support routine care
1
Before Pregnancy ....aka Preconception Care
? Preconception care consists of identifying those conditions that could affect a future pregnancy, and that may be amenable to intervention.
? Dx code V26.49: Other procreative management, counseling and advice
? CPT code 99401-99404
Pregnancy ? But Before OB Global
? How to bill for encounter to diagnose pregnancy ? Patient presents with symptoms ? Patient calls with (+) home pregnancy test
2
Example Office Note
? 25yo, sexually active, SWF, here with CC of nausea x 3 weeks intermittently. Reports irreg menses and uses condoms for birth control. Denies fevers or emesis.
? Exam: (+) UPT, Pt pale, no acute distress, Pelvic exam: No CMT, Uterus about 6-8 weeks size
? Early pregnancy, unknown dates. Schedule transvaginal U/S. Rx for PNV faxed in.
Example Office Note
? 25 yo, sexually active, SWF called earlier today with (+) home UPT last night. UPT in the office today was also (+). Pt reports irreg menses with ? LMP. Discussed with MD and he suggests that the pt be scheduled for an U/S later this week and start on a PNV. Pt in agreement with POC.
? Note signed by medical assistant.
3
Example Office Notes
? 25 yo, sexually active, SWF called earlier today stating that she had (+) home UPT last night. Per MD's POC on date XYZ, the pt presents for a UPT and pregnancy counseling today under the direct supervision of MD. Test here was also (+). Discussed with pt diet changes, exercise limits, s/s to call office, reviewed early s/s of normal pregnancy. Pt reports irreg menses with ? LMP. Discussed with MD and he suggests that the pt be scheduled for an U/S later this week and start on a PNV. Pt in agreement with POC.
Pregnancy Test Codes
? Dx Codes ? V72.40: Pregnancy examination or test, pregnancy unconfirmed (aka possible pregnancy, not confirmed yet) ? V72.41: Pregnancy examination or test, negative result ? V72.42: Pregnancy examination or test, positive result
4
During Pregnancy ....aka Antepartum Care
? According to CPT?, maternity care and delivery are those services normally provided in uncomplicated maternity cases.
? CPT? also states that any other visits or services within this time period should be coded separately.
Antepartum Care
? CPT? guidelines list the following services in the antepartum care package: ? Initial and Subsequent history and physical exams ? Weight, blood pressure, fetal heart tones, routine chemical urinalysis ? Monthly visits up to 28 weeks (5-6 visits) ? Biweekly visits up to 36 weeks (4 visits) ? Weekly visits until delivery (3-4 visits)
5
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