Ob-Gyn Coding Alert

When separately reporting visits,  know exactly what your payer means

If a pregnant patient moves out-of-state mid-pregnancy, do you know how to report the services your ob-gyn provided up to the date of the move? Prepare for these situations by adopting the following approach.

Tip: For 1-3 Visits, Rely on Office E/M Codes

If your ob-gyn sees a patient for only one to three antepartum visits, you need to report the appropriate E/M codes to be reimbursed.
 
Pitfall: For the first ob visit, don't automatically look at a level-four established patient visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity).

You won't have a set E/M code for the patient's first visit, because your patient could be new to the practice, for example, or the first visit may actually meet the criteria for a level-five established visit. Therefore you should look to the entire code series (99201-99205 for new patients, 99211-99215 for established patients) as possible options.
 
For the second and third visits, your coding options are more limited. Medicare values the follow-up visit as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), so this code is your best bet for each of these visits.
 
In some rare circumstances, such as when the patient has absolutely no problems during the visit, however, you may also report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... Physicians typically spend 10 minutes face-to-face with the patient and/or family) for each visit, says Becky Rood, a biller at the Ob/Gyn Associates of West MI, PC in Muskegon, Mich.
 
If the patient's pregnancy is without complication, your diagnosis would be either V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy), Rood adds.

Tip: Anticipate Using Antepartum Codes for 4-6 Visits

Four to six visits mean that you'll be flipping through your book to the maternity care and delivery section - particularly the antepartum codes.
 
"We would report 59425 (Antepartum care only; 4-6 visits), a code that represents the total services rendered by our ob-gyn," says Velvie Burson, practice manager at Carrolton Ob/Gyn in Georgia. This means that you'll only report one unit of this code.
 
Note: Your diagnosis will be the same (V22.0 or V22.1) unless the patient has any problem or complication.

Tip: Prod Payer for Clues for 7+ Visits

You'll find more variation in your coding choices if your patient leaves your practice after seven or more visits. CPT has a code specifically for seven or more visits: 59426 (... 7 or more visits). "I would report one unit of 59426 with diagnosis codes V22 through V23.84, as appropriate," says Patty Wood, practice administrator at Commonwealth Physicians for Women PC in Richmond, Va.
 
Red flag: Avoid reporting global codes at all costs. You can only report a global code if your ob-gyn also does the delivery. Because you're talking about a patient who leaves the practice before delivery, codes 59400-59622 do not apply.
 
Caution: Some payers may ask you to report each visit separately -and you may want to ask them what they mean by "separate."
 
"Separate" may mean reporting 59426 along with a list of the dates, Wood says. This is why you should definitely keep track of a patient's prenatal visits by noting the date the ob-gyn sees the patient.
 
The payer may also want you to report the appropriate E/M code for each visit, but that isn't likely. "I have never encountered a payer that wanted each visit reported separately like this," Burson says.
 
"In the past, a payer has requested that we report these visits separately. We copied the explanation of the CPT code for 59425 and 59426 from the book and forwarded it back to the payer - and haven't heard another word/request since," says Terri R. Viar, CPC-A, an ob-gyn coder at Women's Care PA in Shawnee Mission, Kan.