EM end-result guides you on which ICD code to go for Ob-gyn coding

Situation: A patient came for an initial OB visit. Some other clinic confirmed her pregnancy, but she has never received prenatal care. She received her usual initial OB service (i.e. lab orders), Pap smear, and chlamydia trachomatis (CT)/neisseria gonorrhoeae (GC) screening. After discussing some concerns with the patient, the ob-gyn ordered another pregnancy test, the outcome of which was negative. Then he ordered an ultrasound (US) which showed no intrauterine pregnancy. The ob-gyn noted bilateral polycystic ovaries, however. In short, the office completed the initial OB visit prior to knowledge of a negative pregnancy test (given the confirmation documentation of a positive pregnancy test). I'm not sure whether to bill it as an initial or an office visit. What code should I use for the first diagnosis?


Solution: The suggestion is to code what you know at the end of the visit. Since the patient was not pregnant, you should report an outpatient E/M visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...; 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...). As it turned out, you weren't providing global OB care nor were you supervising a pregnancy after all.


Your final diagnosis should be 256.4 (Polycystic ovaries) with V72.41 (Pregnancy examination or test, negative result). According to the CPT Assistant, you would code the ultrasound as an OB ultrasound (76805-76815). Therefore, you should link the ultrasound to V72.41. Here's what the guideline states:


"For a patient with an established diagnosis of pregnancy (determined by any means), with signs and symptoms that could be pregnancy related and necessitating an ultrasound evaluation of the pelvis, the obstetrical ultrasound code(s) 76805-76815 should be reported, even if the outcome of the procedure is that the patient is now not pregnant or has an ultrasonic diagnosis that might be deduced as being independent of the pregnancy (e.g., acute appendicitis, torsed ovary, necrotic fibroid)."


Report with ICD-10: Your new ICD-10 system will list 256.4 as E28.2 (Polycystic ovarian syndrome). V72.41 will be replaced by Z32.02 (Encounter for pregnancy test, result negative).




Suzanne Leder, M.Phil., CPC, COBGC can answer your ob-gyn coding questions, as she has been the Ob-gyn Coding Alert editor for five years and counting. Also, she holds a specialty OB/GYN coding certification. Currently, she is an Executive Editor at the Coding Institute and has covered topics in cardiology, physical medicine and rehab, gastroenterology, neurology, neurosurgery, orthopedics, and otolaryngology. She has a BA from N.C. State University and an international Master's degree (M. Phil) from Trinity College Dublin.