Tammy Posted Mon 11th of April, 2016 06:29:29 AM
Patient had been seen in office as a new OB referral (5weeks) there was an HPI / exam and MDM and a flow sheet had been initiated. She was asked to come back for her IOB.? she came back a month and a few weeks later for her IOB ( a more thrall exam was done) and her flow sheet was completed. Would her first visit not be an IOB?? the reason I ask is due to it being Medicaid and have to split bill the visits. I am thinking I bill her IOB the first visit since that is when she was seen regardless of the extend of exam??? please let me know your thoughts. thanks so much!! always so helpful!
SuperCoder Answered Tue 12th of April, 2016 09:19:27 AM
Thanks for the Query
Global obstetrical care begins when antepartum services are provided, or the obstetrical record is initiated as part of the physician's comprehensive obstetrics work-up which includes the comprehensive history and physical exam.
he initial OB visit may be reported as an E/M service under certain conditions. Even if the patient has taken a home pregnancy test, the initial visit may still be billed as an E/M service as you will be officially confirming the pregnancy.
When coding for the “initial ob visit”, there are a few things that have to be taken into consideration. First you have to determine if the patient is there for a confirmation of pregnancy or if the pregnancy has already been confirmed. The second thing that needs to be determined is if the OB record has been initiated. Once this has been established you can determine how the visit should be reported.
Here is an example to help clarify the issue:
If a patient presents with signs or symptoms of pregnancy or has had a positive home pregnancy test and is there to confirm pregnancy, this visit may be reported with the appropriate level E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.
For more information please refer to undermentioned link