Ob-Gyn Coding Alert

Reporting obstetrics may be something you do every day, but that doesn't mean your coding will be error-proof.

Review the following three frequently asked ob coding questions -- answered by our experts -- and discover solid advice on what an ob package includes, what hospital services you can report, and what to do if an ob patient is in a car accident.

Question: What services are considered part of the global maternity package (for example, routine dip urinalysis, blood draw, etc.)?

CPT includes a definition of services that are part of the global package in the "Maternity Care and Delivery" section immediately before 59000 (Amniocentesis; diagnostic), says Peggy Stilley, CPC-OGS, ACS-OB, clinic manager at OU Physicians in Tulsa, Okla. The guidelines explain what is included in antepartum, delivery and postpartum services.

Glitch: Some payers may try to include some of the tests performed as screening during pregnancy in the global package, Stilley says.

Example: The CPT definition states that you should include a routine chemical urinalysis to check for glucose and protein. The package, however, does not specify a dipstick. Plus, it does not specify under microscopy or another method. The definition simply directs you to include a routine urinalysis, which is a chemical test. If that is what your ob-gyn is doing, regardless of the method used, you should include the urinalysis 81000-81003 (Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents ...) in the obstetric global package.

Don't miss: Any other test that the ob-gyn performs on a patient during her pregnancy is probably excluded from the global package under CPT guidelines. But you may run into complications.

Example: A physician was getting very nervous because he had been sued previously, so he decided to do an alpha-fetoprotein test (82105, Alpha-fetoprotein [AFP]; serum) on all pregnant patients. The insurance carriers saw that this ob-gyn billed the AFP regularly for all patients and notified him that they were no longer going to reimburse for that service. They stated that the AFP was now recognized as part of his routine obstetric package care, and they were rolling it in. Unfortunately, this is the view of many payers.

Watch out: If your practice consistently bills for things without good medical indication for the particular patient, the insurer will tend to view the service as part of your global package and refuse to pay for it. In other words, you are not performing the service because the patient needed it -- you are doing it on all patients, regardless of need.

Good idea: Ensure that the tests you do outside of the routine urinalysis are medically indicated for the specific patient. For instance, if the patient needed to have some lab work done and the ob-gyn draws blood (36415, Collection of venous blood by venipuncture) to send a sample to the laboratory, you should not include it as part of the global service; the insurer should reimburse it.

  Best advice: When you are dealing with any payer regarding obstetric services, you should spend some time in advance reading your contract or agreement with that payer. You-ll waste time if you bill for services that your contract or agreement clearly states you should include in the global ob package. Plus, you can take this information to your physicians who may have signed off on the contract to suggest they renegotiate the next contract to exclude specific services from the global because you do not perform them on every patient, says Barbara Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Question: What hospital charges can the physicians report for obstetric patients?

You can sometimes bill hospital services outside of the global package. For instance, you could report the admission history and physical (99221-99223, Initial hospital care, per day, for the E/M of a patient ...) and any subsequent care (99231-99233, Subsequent hospital care, per day, for the E/M of a patient ...) if the ob-gyn admits the patient for a complication of pregnancy. But payers will usually not reimburse you for a service that takes place within 24 hours of the delivery.

Gray area: The 24-hour period is open to debate because payers tend to go by calendar dates and not hours in a day or number of hours prior to delivery. Generally, if you admit a patient on day one because of premature labor contractions that you were trying to stop and you deliver on day three, the carrier should pay for day one and two outside the package. The payer would not reimburse separately for day three because that was the date of the delivery, Stilley says.

Also, you can bill separately for procedures (other than labor management) the physician performs while the patient is in the hospital. For instance, most carriers consider induction of labor part of labor management, and hospital staff, not the physician, usually starts the IV. You can use the IV infusion codes (90765-90767, Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug] ...) if the physician personally starts the IV, sits with the patient the entire time, and documents that time.

If the ob-gyn admits the patient to the hospital for a condition and then discharges her without delivery, you can bill for the admission, the subsequent care and the discharge day management (99238-99239, Hospital discharge day management ...).

Question: When an obstetric patient is in a car accident, what diagnosis code should we use with an ultrasound or fetal non-stress test (NST)?

Action: Find out what's wrong.

For instance, your ob-gyn may admit a pregnant patient involved in an automobile accident for observation, even if she has no complaints or signs of injury. In this case, you would use V71.4 (Observation following other accident), V22.2 (Pregnant state, incidental) and an E code for the automobile accident. These three codes will explain the situation. 

Switch: If a patient comes in following an automobile accident and has an injury, this probably will affect the pregnancy. You would call it a complication affecting the management of the pregnancy. Report 648.93 (Other current conditions classifiable elsewhere; antepartum condition or complication) in this case because she has not delivered. List all of the non-ob chapter codes that represent the injuries the obstetrician is treating.

Note: If the patient is seen in the emergency department (ED) and the ED staff takes care of that part, you would not report those services. You would indicate that there is a potential here for conditions elsewhere, etc., but you are not taking care of that part. You may still use the E code (such as E813.x, Motor-vehicle traffic accident involving collision with other vehicle).

Caution: If the accident affects the fetus in any way, such as decreased fetal movement or a change in the fetal heart rate, use a code in the ob chapter. Do not use the E code (E813.x).

Why? You cannot use E813.x with the fetal category codes or any other code outside the ob chapter because the cause code assigns the problem to the mother, and that is not the situation. You are saying something is wrong with the fetus.

If the physician thinks that the injuries are not impacting the pregnancy at all, but he is taking care of those injuries, you are going to bill the injury codes, V22.2 and the E code (E813.x).