Case Study:
Correct Coding of Additional E/M Visits Maximizes Payment
Published on Sat Apr 01, 2000
Ob/gyn coders can increase reimbursement and reduce denials by correctly assigning evaluation and management (E/M) codes for visits above the normal number that are considered part of the global ob care.
Specific scenarios were raised by Patricia Marth, practice manager of College Heights Ob/Gyn Associates, a six-physician, one-nurse practitioner ob/gyn practice that is part of a large, multi-specialty physician group in Allentown, Pa. About 7.5 percent of all College Heights ob patients are high risk.
Marths first example is of a high-risk patient at risk for gestational diabetes and pregnancy-induced hypertension. The patient has had at least six to eight more prenatal office visits than a routine ob, says Marth. Should we add dollars and support that addition with medical records, or should we append our claim with additional E/M codes to account for the extra services? And what, if any, modifiers would be used in this scenario?
Code Extra Visits in One of Two Ways
Typically, the normal global ob package consists of about 13 visits (within a range of 10 to 15). Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature, says that it is acceptable to bill for additional antepartum care dealing with complications of pregnancy in one of two ways. As you suggest, Witt says, you can add modifier -22 (unusual procedural services) to the global ob code and send in documentation in support of the additional visits.
The other alternative, according to Witt, is to itemize each visit beyond the 13th one by reporting an E/M code level that is supported by the documentation in the antepartum record. There are no appropriate modifiers for this situation, says Witt, so just bill the E/M services, making sure you have proper documentation.
Of the two alternatives, itemization or use of the -22 modifier, Witt prefers itemization. Itemization preserves data about the visit, says Witt, but either method may work. There is no need for modifiers when you itemize the visits, as each is a stand-alone service for a complication of pregnancy.
Although the use of itemized visits is most preferable, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C., it would be useful to contact the insurance carriers you deal with most often and ask them which way they prefer. That way, you reduce the instances of delay caused by using a method of billing that is not recognized by the carrier.
Witt says that if the payer denies the additional antepartum visits on the first submission, appeal the decision and be prepared to support the request with additional information. Just make sure your diagnoses [...]
