# Twin delivery coding



## Lisa Bledsoe

Does anyone have links or guidelines on Twin delivery coding?  Or would you say it's up to the insurance as to which way they will pay on twins (2 codes vs one w/mod -22).  I can't seem to find anything definitive.  Thanks in advance!


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## lrcarver

*Twin delivery*

How were they delivered vaginally or c-section?


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## jonvieve

I say call insurance . . . some want -59, -22, -51, or a combo of global and detail codes.  when I called CIGNA International they had me bill 54900 X2 and reimbursed for both, I thought that was odd.  Calling the carrier can help reduce denials.


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## imjsanderson

Ace Your Twin Delivery Claims With 4 Solutions to Your Toughest Questions
Ob-Gyn Coding Alert 2008: Volume 11, Number 12 
Experts advise you to follow whatever modifier rules your insurer has in writing
Hype around celebrity twins has many coders wanting to know how to report a twin cesarean delivery. The answer: 59510 with modifier 22 attached. But that may not always be the case. You'll need to adjust your twin delivery reporting depending on an insurance company's preference.
Tackle these four tricky twin delivery questions and check with your contracts. You'll be submitting picture perfect claims in no time.
1. How Should I Report Twin Delivery?
If a patient is having twins, most ob-gyns first attempt a vaginal delivery as long as the physician hasn't identified any complications.
In this case, you should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second, says Geri Montoya, CPC, coding auditor at Exempla Healthcare in Denver, Colo.
Note: Both CPT and the American College of Obstetricians and Gynecologists (ACOG) recommend you use modifier 51 (Multiple procedures) for the second delivery. But you may encounter some payers who want to see modifier 59 (Distinct procedural service) instead, says Belinda Ziegman, MA, CPC, outpatient coder supervisor at St. Joseph Hospital Physician-Billing Services in Phoenix, Ariz. Other coders report appending modifier 22 (Increased procedural service) to the global delivery (59400) if the patient had more than the average of 13 visits. When this instruction is in writing, you should follow it.
Best bet: Send a letter of explanation with the claim to avoid immediate denial by the claim processor. A simple form letter explaining the high-risk nature of multiple-gestation pregnancies will routinely go straight to medical review and save the hassle of denial resubmissions or lost reimbursement through write-offs, experts say.
2. What If the First Delivery is Vaginal, Second is Cesarean?
If the physician delivers the first baby vaginally but the second via cesarean, assuming he provided global care, report 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care) for the second baby and 59409-51 for the first, Montoya says. You should include 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn) as diagnoses. 
For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the cesarean -- for example, malpresentation (652.6X, Multiple gestation with malpresentation of one fetus or more) -- and the outcome (such as V27.2), Zeigman says.
3. What Should I Do for All Cesarean Deliveries?
When the doctor delivers all of the babies, whether twins, triplets, etc., by cesarean, you should submit 59510 with modifier 22 appended. Because the ob-gyn made only one incision, he performed only one cesarean, but the modifier shows that the physician performed a significantly more difficult delivery due to the presence of multiple babies, Zeigman says.
“This can also depend on carrier. For instance, Colorado Medicaid allows you to bill for both babies, even though the physician makes only one incision,” Montoya says.
Be sure to include a letter with the claim that outlines the additional work that the ob-gyn performed to give the carrier a clear picture of why you're asking for additional reimbursement.
4. What if the Babies Come on Different Days?
Occasionally, multiple-gestation babies will be born on different days. For example, a patient is at 38 weeks gestation and carrying twins in two sacs. One membrane ruptures, and the ob-gyn delivers the baby vaginally. Two days later, the second ruptures, and the second baby delivers vaginally as well.
Here, you should report the first baby as a delivery only (59409) on that date of service. For the second, you should bill the global code (59400), assuming the physician provided prenatal care, on that date of service. The reason not to bill the global first is that you are still offering prenatal care due to the retained twin, Zeigman says.
You will have to attach a letter explaining the situation to the insurance company. ICD-9 will be important to the payment. Be sure to use the outcome codes (for example, V27.2).

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