Ob-Gyn Coding Alert

Here’s what you should do when the nurse delivers the baby instead.

If you’re worried you may have missed a subtle detail in the delivery scenarios on page 43, then compare what you have with what our experts provided.

Your Ob-Gyn Delivers for Unaffiliated Ob-Gyn

Scenario 1: A pregnant patient’s regular ob-gyn is out of town when the patient goes into labor. Your ob-gyn, who is not affiliated with the regular ob-gyn, performs a normal delivery. How should you report this?

Answer 1: You should report the delivery according to how your ob-gyn performed it -- either vaginal (59409, Vaginal delivery only [with or without episiotomy and/or forceps]) or cesarean (59514, Cesarean delivery only). As for diagnoses, you should use 650 (Normal delivery) and V27.0 (Single liveborn).

Keep in mind: You should allow the patient’s regular ob-gyn to bill for the antepartum visits. The delivery only CPT® codes no longer  include postpartum visits in the hospital or discharge care. You would code these services in addition, if provided by the delivering physician or another member of the delivery physician’s group practice.

But if your ob-gyn provides all postpartum care services both in and out of the hospital, you should look to 59410 (... including postpartum care). Use V24.2 (Routine postpartum follow-up) for your supporting diagnosis.

What to Do When Nurse Delivers Instead

Scenario 2: The nurse delivers the baby because the ob-gyn is in the next room doing a procedure on another patient. How should you report this?

Answer 2: You can use a global code (such as 59400). You should probably add modifier 52 (Reduced services) to account for the fact that the ob-gyn wasn’t present. Be sure to include information about which part of the process he did participate in, so you’ll lessen the impact of any fee reduction the payer might apply because delivery includes services like the admission and labor management.

Master Multiple-Gestation Deliveries

Scenario 3: One of your ob-gyn’s regular patients is having twins, and your ob-gyn delivers them both vaginally. How should you report this?

Answer 3: You should report 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care) for the first baby and 59409-51 (Vaginal delivery only [with or without episiotomy and/or forceps]; multiple procedures) for the second. Modifier 51 on the second code is key for reimbursement, experts say.

Caution: Some carriers require you to bill vaginal deliveries broken up into two separate codes with modifier 59 (Distinct procedural service) attached. Other payers will not pay anything additional for twin B when the delivery is vaginal.Nevertheless, your diagnoses will be 651.01 (Twin pregnancy; delivered, with or without mention of antepartum condition) and V27.2 (Twins, both liveborn).

Scenario 4: The ob-gyn delivers the first baby vaginally but the second by cesarean. How should you report this?

Answer 4: You should report 59510 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care) for the second baby and 59409-51 for the first. 

Why: You should bill the cesarean first because 59510 has higher RVUs (relative value units). The RVU for 59409 is 23.96, and the RVU for 59510 is 67.41 — a difference of about $1,556.

The diagnoses for the vaginal birth will include 651.01 and V27.2.

For the second twin born by cesarean, use additional ICD-9 codes to explain why the ob-gyn had to perform the c-section -- for example, malpresentation (652.6x, Multiple gestation with malpresentation of one fetus or more) -- and the outcome (such as V27.2).

Scenario 5: The ob-gyn delivers both babies by c-section. How should you report this?

Answer 5: When the doctor delivers all of the babies — whether twins, triplets or more — by cesarean, you should submit 59510-22. The reason you report only one code is that the ob-gyn is only making one incision.

Focus on this: Report 59510 with modifier 22 (Increased procedural services) appended. The ob-gyn performed only one cesarean, but the modifier shows that the ob-gyn performed a significantly more difficult delivery due to the presence of multiple babies. 

Finally, for the diagnoses, include the reason for the cesarean, 651.01, and V27.2.

Check Your Complications Coding

Scenario 6: During a vaginal and/or cesarean delivery, the patient has a complication. How should you report this?

Answer 6: For complications of pregnancy, the old rule “some are easy, some are hard- comes to mind,” experts say.

If the complication required extra work (such as a third- or fourth-degree repair, or uterine aony after cesarean), you should report the main procedure code (such as 59510) with modifier 22 appended. You should be able to explain the need for this modifier. 

Also, when the patient requires additional services such as extra visits, ultrasounds, and testing that are not included in the routine global ob package, you definitely bill those out, experts say. 

Heads up: When billing for complications of the delivery, you want to make sure you are using diagnosis codes in the 641-677 series. For example, you should report 648.91 (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; other current conditions classifiable elsewhere; delivered, with or without mention of antepartum condition) with a secondary code describing the complication. Remember, ICD-9 codes and documentation are critical to maximize ethical reimbursement for these services.