“CODE THIS!”

Vomiting in Pregnancy in the Third Trimester

by Lori-Lynne A. Webb, CPC and Renée Allen, MD, MHSc., FACOG 

July, 2017 

Case Excerpt (summary and narrative of actual case):

29 year old G1 at 34 4/7 weeks EGA by LMP consistent with an 8 week ultrasound, who presented to OB triage with a complaint of chronic vomiting during pregnancy. The patient reported that she had been vomiting intermittently over the last month.  She had an episode two days prior to, and again the morning of her triage visit.  Her vomiting episodes typically occur in the mornings. The patient reported that the day of admission she ate a breakfast of fruit and granola, then drank water. She then immediately vomited. The patient also reported nausea and mild dizziness.  She denied abdominal pain, diarrhea, painful urination, and other symptoms. She denied eating unusual or spicy foods. She reported occasional constipation for which she takes Miralax.  She works as a Nurse Practitioner on the Internal Medicine Hospitalist Service and reported many ill contacts. 

She reported normal fetal movements and denied vaginal bleeding, leaking of fluid and contractions.  She had been seen by her prenatal care provider Dr. P in the office one day prior and advised that if the vomiting continues she should be evaluated in OB triage.  As the vomiting recurred, she decided that it was time to come to the hospital for further evaluation.

Labs 

A CBC and CMP were obtained.  While in OB triage, the patient declined IV fluids and IV anti-emetics.  The patient was able to take nap while waiting for her labs to return and reported that she did feel better after resting.  She was also able to drink a glass of water and pass an oral challenge test. She had no vomiting episodes during her evaluation. The patient stated that she felt better after observation and indicated that after 1.5 hours of monitoring and observation in OB Triage, she felt that she could return to work.

The final diagnosis and assessment provided by the OBGYN Hospitalist was

The patient was discharged home in stable condition with preterm labor precautions, fetal kick counts instructions, instructions to continue taking Miralax as needed for constipation, maintain a BRAT diet for 1 week and instructions to follow up with her local OB/GYN in 5-7 days.

As the OB hospitalist, how would your services be coded?

ANSWER:

Coding Brief

The OB/GYN hospitalist in this case correctly assigned, based on the patient’s presenting history, signs, symptoms and clinical examination, a diagnosis of Late Vomiting in Pregnancy and Constipation.

Under ICD-10, any pregnancy complication diagnosis code must be accompanied by a code in the Z3A family, specifying gestational age. Also per the ICD-10 guidelines, if the trimester is known, it is to be coded, in addition to the weeks of gestation.  In this case Z3A.34 denotes 34 weeks gestation.

A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient (OB Triage) or other ambulatory facility.  New patient visits are limited to one every three years, per client, per provider. Usually the presenting problems that support CPT code 99204 are of moderate to high severity. Counseling and or coordination of care with other providers or agencies are provided as well.

Or, if coding is based on time, physicians typically spend 45 minutes face to face with the patient if employing this particular code.
In contrast, an established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility. In the case of OB triage, if this patient was seen by any member of the OBGYN Hospitalist team on a previous date within the last 3 years, these codes would be applicable. The same documentation criteria apply for this type of encounter as noted above for new patients encounters.

Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. In this case, the NST interpretation also occurred on the same days as the evaluation for vomiting. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client’s medical record.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC and ICD10 CM/PCS Ambassador/Trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail or you can also find current coding information on her blog site. 

Dr. Renée Allen served as co-author of this column.  She is Chair of the SOGH Coding Committee and is the SOGH Liaison to the ACOG Committee on Health Economics and Coding.  She currently works as an OB/GYN Hospitalist with Mednax/Obstetrix at Eastside Medical Center in Snellville, Georgia.