Obgyn Encounter Form – Fill Out and Use This PDF

The OB/GYN Encounter Form is a critical document designed to streamline the documentation and submission process for claims related to obstetric and gynecological care. It is addressed to the Claims Department of Amerigroup and includes various sections for member and provider information, CPT (Procedure) Codes for different types of visits, diagnosis codes, and specific codes for counseling, cancer screening, pregnancy, postpartum, and other preventive measures. To ensure accurate and prompt processing of claims, it is imperative for healthcare providers to fill out the form thoroughly and accurately by clicking the button below.

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Obgyn Encounter Form PDF Details

In today’s healthcare landscape, the documentation of patient encounters, especially in specialized fields such as obstetrics and gynecology (OB/GYN), is of utmost importance for both clinical accuracy and efficient billing practices. The OB/GYN Encounter Form serves a critical role in this process by facilitating a streamlined approach to capturing vital patient and provider information, while also adhering to billing requirements set forth by insurance entities, such as Amerigroup. This form meticulously outlines details such as member and provider identifiers, the date of the visit, diagnostic codes, and specific procedures performed, categorized by CPT (Current Procedural Terminology) codes and relevant ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes. Moreover, it encompasses a broad spectrum of services within the OB/GYN purview, from preventive and office visits to counseling, cancer screening, and even postpartum care. Designed to be sent to the claims department for processing, this form embodies the intricate balance between clinical care and healthcare administration, ensuring that the wide array of encounters within the OB/GYN setting are documented accurately for both the patient’s medical record and for insurance reimbursement purposes.

Question	Answer
Form Name	Obgyn Encounter Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	gyne encounter forms, ob encounter, ob gyn encounter sample, ob gyn encounter form template

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OB/GYN Encounter Form

Mail to:

Claims Department

Amerigroup

P.O. Box 61010

Virginia Beach, VA 23466-1010

Member Information	Provider Information

Last Name:	Provider Name:

First Name:	Phone #:		Provider ID #:
Member ID #:	Date of Birth:	Fax #:		Date of Visit:

	Address:

Level of Care: Please circle at least one CPT (Procedure) Code.

	Preventive/Physical				Office Visit			Counseling
	Preventive/Physical				Office Visit			Counseling

Age		New Patient	Established		New Patient	Established		Code	Length of Time
			Patient			Patient

12–17		99384	99394	99201		99211	99401		15 minutes
18–39		99385	99395	99202		99212	99402		30 minutes
40–64		99386	99396	99203		99213	99403		45 minutes
65+		99387	99397	99204		99214	99404		60 minutes

				99205		99215

Diagnosis Codes: Please indicate primary, secondary, and tertiary codes (1, 2, 3).

*If elements of wellness care were performed, please mark a wellness code as a secondary diagnosis.

Well Care/Preventive ICD-9 Codes	___ V67.9 Follow-up Exam, Unspec	___ 645.03 Prolonged, Antepartum
___ V70.0 Routine Physical (12+)	Contraception	___ 651.03 Twins, Antepartum
___ V70.3 General Medical Exam	___ V25.01 Rx Oral Contraceptive	Menstruation
___ V70.5 Health Exam	___ V25.02 Initiation, Other Contrcp	___ 636.8 Abnrml Bldg Genital Tract
	Method
___ V70.6 Health Exam in pop survey	___ V25.09 Mgmt, Contrcp, Other	___ 626.0 Amenorrhea

___ V70.8 Other specified gen med exam	___ V25.40 Surveillance, Unspecified	___ 625.3 Dysmenorrhea

___ V70.9 Gnrl Medical Exam, unspec	___ V25.41 Surveillance, Oral Cntrcp	___ 626.4 Irregular Menstrual Cycle
Counseling ICD-9 Codes	___ V25.49 Surveillance, Other	___ 627.2 Menopause/Clmctrc sts
	Method
___ V65.3 Dietary Counseling	Cancer Screening	___ 626.6 Metrorrhagia
___ V65.41 Exercise	___ 233.1 CA in Situ, Cx	___ 627.1 Postmenopausal Bldg

___ V65.42 Substance Use/Abuse	___ 622.1 Dysplas Cx (Uteri)	___ 626.2 XS/Frequent Menstruation

___ V65.43 Injury Prevention	___ 218.9 Leiomyo Uter, Unspec	GYN
___ V65.44 HIV Counseling	___ 184.8 Malgn Genital Neoplasm	___ 789.00 Abdominal Pain
___ V65.45 STD Counseling	___ 180.9 Malgn Neoplasm Cx	___ 112.9 Candidiasis, Unspec

___ VTOB Tobacco	Pregnancy Postpartum	___ 112.1 Candidiasis, Vulva/Vagina
Other Preventive ICD-9 Codes	___ 637.91 Ab. Legal, Incomplete	___ 616.0 Cervicitis/Endocervicitis
___ V76.2 Routine Pap Smear	___ 635.92 Ab. Legal Induced,	___ 595.0 Cyctitis, Acute
	Complete
___ V22.2 Pregnant State, Incidental	___ 634.91 Ab. Spon, Incomplete	___ 628.9 Infertility, Female

PF-ALL-0078-12

___ V22.1	Pregnancy, Supervision Other		___ 634.92 Ab.Spon, Complete		___ 616.9 Inflam dx of cx/vag/vulva
Norm
___ V23.7	Supervision, Hi Risk, Insuff		___ 640.03 Ab. Threatened,		___ 623.5 Leukorrhea
Prenatal			Anteprtm
___ V28.8 Screening, Antenatal, Other			___ 669.71 C-sect w/0 mention of		___623.8 Noninflam dx of Vagina
spec.			indic
___ V23.89 Supervision, Other High Risk			___ 650 Delivery, Normal		___ 620.2 Ovarian Cyst

___ V23.9	Supervision, Unspec High Risk		___ 633.9 Ectopic, Unspec		___ 614.9 PID

___ V27.0	Mother with single liveborn		___ 655.83 Fetal Abnormalities		___ 618.8 Uterine Prolapse
___ V61.5	Multiparity		___ 656.3 Fetal Distress		___ 599.0 UTI
___ V24.1 Postpartum Care and Exam			___ 656.53 Fetal Growth, Poor		___ 618.0 Vaginal Prolapse
Lactat Mthr

___ V24.2 Postpartum, Routine			___ 656.63 Fetal Grown, Excess		___ 054.11 Vulvovag, Herp

___ V67.0	Follow-up Exam After Surgery		___ 644.13 False Labor		___ 131.01 Vulvolag, Trich
___ V58.49 After Care for Surgery			___ 653.53 Fetal Growth, Unusually		___ Other
			Large
___ V72.4	Test, Pregnancy Unconfirmed		___ 648.8 Gestational Diabetes		___ Other
___ V61.7 Unwanted Pregnancy, Other			___ 659.63 Pregnancy > 35 years of		___ Other
			age

___ Other			___ Other		___ Other

Laboratory Tests/Screening – For Data Collection Purposes
___ 83036 HbA1c		__ 84520 BUN		___ 82951 GTT		___ 87110 Chlamydia (culture)
___ 83655 Blood Lead		__ 80061 Lipid Panel		___ 86901 Rh		___ 87590 GC (direct probe)

___ 88141 Pap Smear		__ 84439 Free T4		___ 86762 Rubella Titer		___ 87340 HepB surface antgn

___ 85025 CBC With Diff		__ 87086 Urine Culture		___ 82106 Alpha-		___ 87528 Herpes simplex (dir)
				Fetoprotein

___ 86900 Blood Typing		__ 81000 Urinalysis		___ 83661 Fetal Lung Mat		___ 87207 Herpes (smear)
				(L/S)
___ 86580 Mantoux Test		__ 84550 Uric Acid		___ 86592 VDRL		___ 82043 Microalbumin
(TB)						Quantity

Print Physician Name

Physician Signature and Date of Signature

PF-ALL-0078-12

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Step no. 1 of completing ob gyn superbill

2. The next part is to fill out these blanks: V Routine Physical V General, Contraception V Rx Oral, Twins Antepartum Menstruation, Method, V Health Exam in pop survey V, V Surveillance Oral Cntrcp, MenopauseClmctrc sts, V Mgmt Contrcp Other, Amenorrhea, V Dietary Counseling V Exercise, Method, Cancer Screening CA in Situ Cx, Complete, and Metrorrhagia Postmenopausal.

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4. The form's fourth subsection arrives with the following blanks to focus on: V Pregnancy Supervision Other, AbSpon Complete, Inflam dx of cxvagvulva, Norm, V Supervision Hi Risk Insuff, Ab Threatened, Leukorrhea, Prenatal, Anteprtm, V Screening Antenatal Other, Csect w mention of, Noninflam dx of Vagina, spec, indic, and V Supervision Other High Risk V.

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Uric Acid, Print Physician Name, and Fetal Lung Mat in ob gyn superbill

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Obgyn Encounter Form – Fill Out and Use This PDF

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