We provide global maternity care for OB patients and typically bill 0502F (non-Medicaid). Say for instance, the patient has pre-existing diabetes and lists it as a diagnosis on the prenatal flow sheet. Patient comes in for a routine prenatal visit (0502F) but doesn’t mention anything about the diabetes….can I still attach the pre-existing diabetes diagnosis on that visit even though it wasn’t addressed at that visit but was found on the flow sheet?

I get that a visit note must stand alone….but this is part of global OB care and that prenatal flow sheet is documenting all her antepartum care.

Thanks for any input!