Office visit service for pregnancy confirmation

[Sriram_Sub]

Hello friends,

      We tried billing a 99203 (Office Visit) to DSHS Medicaid on behalf of a patient who came to the PCP for pregnancy confirmation. She was then routed to an OB-Gyn Specialist. When we billed 99203 with V22.2 as the ICD, our claim was denied stating "Procedure is inconsistent with Modifier or a required modifier is missing". The patient was not diagnosed with any other problem on that day. Just trying to understand if a modifier is really required or is the denial related to an issue with the ICD? Please throw some light. Thanks.

Regards,
Sriram

[Michele]

Are you the patient's PCP office?  How did she suspect the pregnancy?  Missed menses or morning sickness?  You may need to use the diagnosis that caused her to suspect the pregnancy rather than the actual pregnancy dx.

[Sriram_Sub]

Yes. The provider is a PCP. It seems the patient came in to meet the PCP first in order to be referred to a specialist. Because it was found that she was pregnant for 4 months as on service date and our PCP reviewed her Ultrasound reports, Lab test reports, Discharge summary and the complete chart notes from a former facility where those tests were taken.

[Michele]

What was she being referred to the specialist for?  The pregnancy?  Did she suspect she was pregnant and if so, why?  I think that is where your problem is.  You are using the end dx of pregnancy when you should be using a primary dx of the reason she came.  i.e. missed mense, nausea, vomiting, weight gain, etc.

[Sriram_Sub]

Thanks for responding, Michele! The patient seems to have had her last mens., 4 months ago (in Jan) and when she had nausea and Pain she did a pregnancy test using a kit by herself. Also, she went to an ED because of the pain and Nausea where the pregnancy was confirmed based on ultrasound reports, Lab tests and other related reports. The patient then came to our PCP for an office visit for the first time and it sounds like the purpose of the visit was just to be referred to a specialist. Our PCP reviewed her reports and did refer her to a specialist. She could not use any other ICD than the pregnancy confirmation which was denied. Hope this info helps.

Regards
Sriram

[PMRNC]

I agree with Michele, I would think there needs to be something else she came in for, she had to have had the pregnancy confirmed (proof of positive pregnancy)
If there is no other code that the record would reflect, I would think there is not much to do. If Medicaid was requiring a PCP referral I would call them up and ask them what to do. Usually the patient brings in proof of positive pregnancy test to the OB, if she got test there and diagnostic test to confirm maybe that's what you need.

[Sriram_Sub]

Thanks for your response, Linda! There is nothing else recorded on the clinical notes. Let me check with the doctor to see if there was any other problem that the patient came for.

Regards
Sriram

[Michele]

It doesn't have to be 'another' problem.  But can't you use pain, nausea, or missed mense as primary and then pregnancy as a secondary dx?

[PMRNC]

It doesn't have to be 'another' problem.  But can't you use pain, nausea, or missed mense as primary and then pregnancy as a secondary dx?

SO LONG AS IT is in the Medical Record.. remember if it wasn't documented, it wasn't done.