Ob-Gyn Coding Alert

Two to three times a yearmore often than shed likecoder Jeanne Folmer has to submit charges for an ob patient who has delivered her baby outside of the hospital. Folmer works for Mid-Dakota Clinic in Bismarck, ND, and although Bismarck is the state capital, some patients come from as far away as 150 miles for their care. And sometimes, the baby arrives before the expectant woman reaches the facility.

If the patient delivers in the ambulance, then we dont get the delivery code, Folmer says, noting that the ambulance cant bill for the delivery either. Nobody gets paid for the delivery in this scenario.

Barbara Johnston, senior billing representative for Oak Tree Womens Health in Middleburg Heights, OH, also knows what its like to miss out on billing for a delivery. We had one patient who wanted to deliver at home using a midwife. We dont normally do that, but we had her sign some consent forms, and billed her for the antepartum care only, Johnston says. We then use 59430 (Postpartum Care Only) for the six-week check-up.

Folmer and Johnston face different but related coding dilemmas, each of which involves an ob patient who fails to deliver in the hospital or birthing center. Lets examine each of these situationsand some others similar to themto determine correct coding and ensure optimal reimbursement.

When the Patient Delivers in the Ambulance En Route to the Hospital

The AMA states in the CPT Companion that any time a baby is not delivered by the physician or practice provider, antepartum care should be coded using the partial antepartum codes 59425 (for 4-6 visits) and 59426 (for 7 or more visits). Fewer than 4 visits are coded using the Evaluation and Management (E/M) office codes. The reason for using these antepartum codes instead of the E/M codes is that they carry greater Relative Value Units (RVU).

For postpartum care, the CPT offers only one code59430. This is the code that both Folmer and Johnston use for Postpartum Care Only, regardless of whether the care is provided in the hospital or on an outpatient basis.

There are several modifications to this situation that affect correct coding. For example, the patient may deliver the baby in the ambulance, but she may arrive at the hospital in time for her ob/gyn to deliver the placenta and admit her for a hospital stay. In this case, coders have the option of billing separately for the antepartum care, the postpartum care, and Delivery of the Placenta Only, using 59414. This is what Folmer does. Another option is to bill using the Global ob code (59400), which covers antepartum care, vaginal delivery and postpartum care. This is the billing method that Johnston frequently uses, and she reports no problems from payers. To be even more precise, she could amend the Global with a 52 modifier (Reduced Services) signifying that the ob/gyn did not perform all the parts of the Global Ob package (i.e. the physician did not deliver the baby). ACOG recommends using the 52 modifier since it more accurately reflects what the ob/gyn has really done for the patient in instances like these.

When the Patient Delivers at Home, but Goes
to the Hospital for Follow-Up

This situation is akin to that described by Johnston in which the patientfor whatever reasondelivers both baby and placenta in a location apart from the hospital. In this case, the ob/gyn is not at all involved in the delivery, and therefore cannot honestly use the Global Ob code. Instead, ob services must be divided into antepartum, delivery and postpartum care, and the ob/gyn can bill only for those services that he or she actually provided.

Antepartum care should be billed using the partial antepartum codes (see box in next column). Postpartum care can be billed using 59430 or, if the patient is admitted, using the E/M codes for Initial Hospital Care (99221-99223). If the patient is at the hospital for observation only, then this can be recorded using Initial Observation Care (99218-99220). These codes have similar requirements for history, examination, and medical decision-making as office E/M codes.

When the Patient Delivers in the Hospital,
but the Ob/Gyn is Not Present

Sometimes, patients deliver at the hospital, but their ob/gyn is not present because he or she was called away to another, more critical patient or because the baby arrives before the ob/gyn reaches the patients side. In these cases, the Global Ob code can be used. The reason for this is that the Global code intends that the physician manages labor and assumes the risk for the patient during her pregnancy, including delivery. If the patient is in the hospital and the ob/gyn is on the premises or en route to the patient, then he or she is playing some role in her care and is able to bill for that role.

The only time that an ob/gyn may not bill a Global is when his or her patient delivers in the hospital but another physician from another practice assumes the care of the patient and bills for delivery separately. For example, your practices ob/gyn is on vacation, and an ob/gyn from another practice performs the delivery. In this case, you would be able to bill for antepartum and postpartum care at the six-week check, while the other physician would bill for the delivery and any postpartum care that he provided immediately thereafter, using 59409 (Vaginal Delivery Only).

Tip: When a covering physician delivers the baby and you have an arrangement with that physician to cross-cover, the global should be billed by the ob who has provided all of the antepartum care.


Vaginal Delivery Code Summary

59400 - Global Ob code, includes antepartum care, vaginal delivery, postpartum care

59409 - Vaginal Delivery Only (includes inpatient postpartum care only)

59410 - Vaginal Delivery and Postpartum Care

59414 - Delivery of Placenta Only

99211-99215 - E/M codes for Antepartum Office Visits (1-3 only)

59425 - Antepartum Care Only (4-6 visits)

59426 - Antepartum Care (7 or more visits)

59430 - Postpartum Care Only (includes outpatient postpartum care only)

-52 Modifier - Reduced Services