Ob-Gyn Coding Alert

When a physician reports 59510 (routine obstetric care including antepartum care, cesarean delivery, and postpartum care), the global period for postpartum care is usually six weeks. Any complications that arise during this period, whether related to the pregnancy and/or surgery, must be coded and billed with that global coverage in mind. But coders may be surprised to know that most post-cesarean complications are billable.

In the definition for maternity care and delivery services, CPT indicates that the global obstetric package includes antepartum care, delivery services, and inpatient and outpatient postpartum care in uncomplicated maternity cases. CPT further clarifies that medical and surgical complications of pregnancy should be reported separately. Using this definition and that for global surgical care, the American College of Obstetrics and Gynecology (ACOG) publishes an annual coding manual, Components of Correct Procedural Coding. The guide lists those CPT Codes most pertinent to the ob/gyn specialty, lists those services included in global billing, and those excluded and therefore separately billable. This guide can be ordered at ACOGs Web site (http://sales.acog.com) or by telephoning (800) 762-2264.

Know What Is Included in 59510

For 59510, the guide lists the following services as included in the postpartum portion of the global service:

Recovery room visit;

Uncomplicated inpatient hospital postpartum visits;

Uncomplicated outpatient visits until six weeks postpartum; and

Removal of sutures, staples.

Per ACOGs guidelines, routine follow-up care is included in the global service. This includes such things as checking an incision during a post-op visit and cleaning and redressing the surgical wound. But what of other, more complicated care that arises from the cesarean surgery?

The guide goes on to list those procedures not included in the postpartum services for 59510. These include:

Inpatient or outpatient medical problems not related to pregnancy;

Inpatient or outpatient medical problems or complications related to the pregnancy;

Management of surgical problems arising in the postpartum period; and

Tubal ligation during the same hospitalization.

Most Complications Are Billable

Postoperative complications following a cesarean section can range from minor wound infections and breast infections to disrupted sutures, highly septic wounds and internal bleeding. Any of these conditions is considered, per ACOGs interpretation, separate from routine global post-op care. How they are billed and coded will depend on the nature of the complication.

Minor infection For a wound or breast infection that can be treated in the office, the appropriate diagnosis code should be paired with the evaluation and management E/M code for the treatment of the infection. In the case of cesarean wound infection, the ICD-9 code is 674.34 (other complications of obstetrical surgical wounds, infection, postpartum condition or complication). For the breast infection, the appropriate diagnosis code is 675.04 (infections of nipple, postpartum condition or complication).

The E/M service may involve an examination, discussion with the patient about treatment options and perhaps the writing of a prescription for antibiotics. An established patient E/M code can be billed (9921x, office or other outpatient visit for the evaluation and management of an established patient ...) for this service, and the level will depend on what has been documented in the chart. Because there is no CPT modifier that describes a post-op complication other than those requiring a return to the operating room, a detailed note from the physician explaining the nature of the problem and its treatment should accompany the claim for the additional E/M service.

Major infection or disruption A widespread wound infection or stitches that pull and result in internal bleeding are serious complications that require an almost immediate return to the operating room to correct. If the patient is bleeding or has a major infection, this is far from routine post-op care and is separately billable, says Evelyn M. Gross, CMM, CPC, NR-CMA, manager of physician practice and new business for Bayshore Community Health Systems, a physician practice management consulting firm in Homedale, N.J.

The infection (674.34) or the disruption of cesarean wound (674.14) and hemorrhaging (also 674.34) would be linked to the appropriate procedural codes. For the cleaning and drainage of the infected wound, 10180 (incision and drainage, complex, postoperative wound infection) would be used. For the disruption and bleeding, 13160 (secondary closure of surgical wound or dehiscence, extensive or complicated) applies. Either of these codes should be appended with modifier -78 (return to the operating room for a related procedure during the postoperative period) if they are performed in the hospital operating room (OR).

Unrelated service If the postpartum cesarean patient reports with a complaint of a strep throat or other condition unrelated to the pregnancy, the physician can treat her using the appropriate E/M code for an established patient and append modifier -24 (unrelated evaluation and management service by the same physician during a postoperative period). If the complaint has nothing to do with the pregnancy itself, you can always bill for the services, even in the six-week global postpartum period, says Gross.

For unrelated surgical services that take place during the hospital stay, such as a tubal ligation (58605, ligation or transection of fallopian tube[s], abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization), the CPT code can be reported with modifier -79 appended for unrelated procedure or service by the same physician during the postoperative period. Services requiring a return to the OR within the global period of six weeks following delivery that are unrelated to the original surgery would also need -79.
Although unusual, an example of this might be a myomectomy (58140, myomectomy, excision of fibroid tumor of uterus, single or multiple [separate procedure]; abdominal approach) for the removal of a growth that was totally unrelated to the pregnancy and c-section.

Medicare/CHAMPUS and Postoperative Care

The above billing guidelines will hold true for most commercial payers, but Medicare has different ideas about what is included in the global postsurgical period. Under Medicare rules, the only complications during the post-op period that are paid are those requiring a return to the operating room, not treatment in the office, says Melanie Witt, RN, CPC, MA, an independent ob/gyn coding educator. A few other commercial payers have adopted this policy, but fortunately, not many.

The CHAMPUS/Tricare military health program also has established rules for reporting post-op complications. It will allow payment for a return to the operating room, but will not reimburse additionally for medical complications until the patient has been seen twice on an outpatient basis following the cesarean.