Ob-Gyn Coding Alert

Here’s why you should be careful about your 1-3 visit situations.

When you’re coding split antepartum visits, you have to be particularly careful. Depending on the number of them, you will report either an E/M visit or a single unit of an antepartum visit code.

Take this four-question true/false challenge to see how you fare.

Question 1: Determine Antepartum Care Definition

True/False: CPT^® states that antepartum care includes monthly visits up to 28 weeks gestation, biweekly visits up to 36 weeks gestation, and weekly visits until delivery.

Solution: True. Ob services include obtaining the patient’s history, performing a physical exam, recording vital statistics, and doing other examinations necessary to provide safe and appropriate care for the mother and fetus.

Question 2: Does Splitting Visits Mean No Global?

True/False: When you split out antepartum care for a patient halfway through her pregnancy, you should completely throw out global ob package codes.

Solution: True. When your obstetrician shares routine maternity care with a physician outside a group practice due to transferring into or out of your practice, you will have to abandon the following global codes:

• 59400 — Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care
• 59510 — Routine obstetric care including ante-partum care, cesarean delivery, and postpartum care
• 59610 — Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care, after previous cesarean delivery
• 59618 — Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.

Do not break the package just because a maternal fetal specialist also sees the patient for a few visits during the pregnancy as a result of a complication.

Bottom line: Once you are splitting the global package into pieces, you would not go back and use a global code for any portion of the obstetrical care, experts say. Of course, there is always a possibility of a particular insurance carrier wanting something different, so always check to see what codes the carrier wants to report the care.

Question 3: Rely on E/M Code for This Number of Visits

True/False: If the patient had a total of one to three antepartum visits, report the appropriate level of E/M service for each visit with the date of service that the visit occurred and the diagnosis for why the patient was seen.

Solution: True. This is correct according to the American Congress of Obstetricians and Gynecologists (ACOG) and CPT^® guidelines.

For example, if the doctor sees an ob patient twice before she moves to a different area, you would report the appropriate E/M code (99201-99215) for each visit with one of the following ICD-10 codes assuming there were no complications addressed at the time of the visit:

• Z34.00 (Encounter for supervision of normal first pregnancy, unspecified trimester),
• Z34.01 (... first trimester),
• Z34.02 (... second trimester),
• Z34.03 (... third trimester).
• Z34.80 (Encounter for supervision of other normal pregnancy,  unspecified trimester),
• Z34.81 (... first trimester),
• Z34.82 (... second trimester), or
• Z34.83 (... third trimester).

Question 4: Be Watchful of Your Antepartum Visits

True/False: If the ob-gyn sees the patient four to six times before she leaves his care, you will report 59425 for each instance the ob-gyn sees the patient.

Solution: False. You should report 59425 one time only.

Because 59425 (Antepartum care only; 4-6 visits) represents the total work involved with all the visits, you should submit it only once with a “1” in the units box of the CMS-1500 claim form. Also, be sure to include the “to” and “from” dates during which the services occurred. Enter the first prenatal visit in box 15 and only enter the last visit the patient was seen for prenatal care in box 25a.

Bonus: Similarly, if your physician provides seven or more antepartum visits, you should report 59426 (... 7 or more visits) only once. As with 59425, you should place a “1” in the units box. You should also record the “to” and “from” dates for the services your ob-gyn provided.

Add This Best Advice to Your Coding Practices

To avoid reimbursement hassles, be sure to ask your carriers how to code multiple antepartum visits. Each carrier may have different requirements for reporting services -- especially those services that vary from the usual — and physicians must know how to correctly report the services they provide to be compliant and to receive appropriate reimbursement for the services provided. You must find out what the patient’s insurer wants in order to bill these services and avoid denials, experts say.

Some payers may allow you to bill an E/M service instead of the antepartum visit package codes. Reporting individual visits allows you to get paid at the time of service rather than waiting until you complete the required number of visits and bill the corresponding code.