tci ED Coding & Reimbursement Alert - 2014 Issue 9

You Be the Coder: Check the Chart for Additional Services When Delivering a Baby

Question: Can I bill for an E/M service in additional to the delivery of a baby given the chart documentation below?  Colorado Subscriber Patient arrived in triage screaming “I’m having a baby”, immediately wheeled into the exam room. Patient was at 40 weeks gestation G4P3 and had been having severe lower abdominal intermittent contractions for 5 hours when her water broke.  She reports this is consistent with prior deliveries.  She has not had diabetes, and she has three prior normal delivers. She denies chest pains. The remainder of history is unable to be obtained...

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