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Ob Gyn coding: Do away with your improper subsequent care coding habits

By Expert Author: Angela MArtin

If you report 99231 for all your subsequent hospital care services, you are certainly wrong because doing so could land you in a tight spot.


According to CMS, Ob Gyn coding use 99231 more than any other subsequent hospital care code. This means that most subsequent hospital visits are either low-level services or Ob-Gyns regularly undercode for inpatient care. Since not all Ob-Gyn visits are low level, you need to report higher-level subsequent hospital care too. This is provided, of course, if your documentation warrants it.


Carriers usually bundle hospital care into post surgical visits. As such, many Ob Gyn coders are not familiar with the documentation guidelines associated with subsequent hospital care for non surgical situations. For instance, if you take up the patient’s care after another physician admits the patient to the hospital, you need to use 99231-99233.


One way to ensure correct coding is to know the coding levels. Here are the basic guidelines for the three subsequent hospital care levels:


  • 99231: You need to report this when the patient is stable, recovering or improving.

  • 99232: Go for this if the patient is responding inadequately to therapy or has developed a minor complication.

  • 99233: Report this when the patient is unstable or has developed a significant complication or a significant new problem.


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