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OB Documentation and Coding

Brian Elkins, M.D.Modified by Brittany Wyger, M.D. (PGY-III)

Change to OB navigator - this is under “helper navigators” drop down

Create a Pregnancy Episode at 1st visit and link episodes at every subsequent visit

Link each visit to the episode

Initial charting

Initial Charting

Initial visit charting

Order prenatal labs

Charting in subsequent visitsUse OB templates for notes

Running an episode report

Running an episode report

Billing correctly

Pregnancy Diagnosis Codes:V22.0 Supervision of normal first pregancyV22.1 Supervision of other normal pregnancy654.20 Previous C-Section643.00 Mild hyperemesis gravidarum

Medicaid Billing:Bill each antepartum visit with LOS and “TH” modifier (99213 + TH)The initial prenatal visit is coded as a new patient, even if not new to our clinic (99203)

Private Insurance Billing:The first 3 visits billed with LOS (no TH modifier)Subsequent prenatal visits go under a global fee, use LOS with “NC” modifier, the global fee will be billed after delivery (faculty does this)