QUICK E/M CODING GUIDE FOR OB/GYN RESIDENTS

PRENATAL CARE New Prenatal Visits For Patients Not Seen In Clinic Within Past 3 Years 99204: New prenatal visit, attending must see patient 99203: New prenatal visit, attending did not see patient Return or New Prenatal Visits For Patients Seen In Clinic Within Past 3 Years 99213: Return or initial, routine prenatal visit, attending did not see patient 99214: Return or initial, high-risk visit or diabetic clinic patient, attending must see patient Postpartum Visits 59430: 1 PPV (2 wks), do depression screening, attending did not see patient 59430: 2nd PPV (6 wks), do depression screening and routine care, attending did not see patient
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GYNECOLOGICAL CARE New GYN Visits 99204: New patient, patient not seen in clinic within 3 years, attending must see patient 99203: New patient, patent not seen in clinic within 3 years, attending did not see patient Return GYN Visits 99212: simple (e.g., vaginitis, cystitis), attending did not see patient 99213: moderate complexity (e.g., breast lump, annual visit), attending did not see patient 99214: complicated (e.g., infertility, pelvic mass), attending must see patient CONSULTATIONS Requirements 1. Written order or request 2. Written reason for consult 3. Written report with findings and recommendations for treatment Initial Consultations

99243: Specialists input required, attending must see patient 99244: Complex consultation, attending must see patient Follow-up Consultations Use codes 99212, 99213, and 99214 as above