|October 2004 · Vol. 16, No. 10
E/M visit before Ob care: What’s OK?
RN, CPC, MA
You may include any service that is not part of the Ob global package in the E/M visit.
Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.
Q The American College of Obstetricians and Gynecologists instructs us to bill an evaluation and management (E/M) visit with the ICD-9 code for suppression of menses (626.8) if the Ob record is not initiated. I simply need to document the patient’s signs and symptoms; if I determine she’s pregnant, I can start the Ob record at her next visit.
My question is, what other services can I provide at this E/M visit? Can I order prenatal labs? Gyn probe? Prenatal vitamins? I don’t want to cross the line.