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Ob-Gyn Coding Alert

Coding Scenario:

Get Paid for Prolonged Care During a Consult

Published on Tue May 03, 2005

Warning: You may not be able to count all of your ob-gyn's time as prolonged

If your ob-gyn is asked to perform a consultation in the hospital that lasts fifteen hours, you may have a case for reporting prolonged services - but you'll have to be careful about adding up the face-to-face time with the patient and making a case that this situation wasn't a transfer of care.

Scenario: Another provider called in our ob-gyn for a consult in the hospital. The ob-gyn was asked to evaluate the patient's fetal heart tracing and made a recommendation. At the time of the consult, she noted, "spontaneous rupture of membranes with labor augmentation," which was then discontinued.

She reviewed with the patient and spouse all of the variables of labor and the possible need of c-section due to the increased fetal heart rate variability. Our ob-gyn remained in the hospital about 15 hours over the course of the patient's labor, closely observing the monitor strip periodically and monitoring fetal well-being. She was in the room to ensure the patient and the fetus did well during the delivery.

Prior to the delivery, the patient's regular provider was not in the hospital and requested that the nurse ask our ob-gyn for her opinion of the fetal heart tones tracings on the monitor. Our ob-gyn has all this documented in her dictation.
 
Question: I know I can charge out the consult, but can I report prolonged care?

To start, CPT has a code that describes a consultant performing fetal monitoring during labor, including the written report and supervision and interpretation - 59050 (Fetal monitoring during labor by consulting physician [i.e., non-attending physician] with written report; supervision and interpretation). You would report 59050 at least two times.

As for whether you can bill the E/M service, you'll have to figure out whether this is a true consultation or your ob-gyn took over partial care of the patient. How your payer will view concurrent care will determine whether you can report anything other than 59050. For the initial visit, you may try to report an initial inpatient consultation (99251-99255). After that, your coding gets tricky.

Decide Between These 2 Options

Option 1: The ob-gyn provided a consultative service, performed the services described by 59050 several times, and was called back to do another follow-up consultation (99261-99263). Keep in mind that if this follow-up consultation happened on the same day as the initial consultation, you should not separately report it. Instead add up all consultative care for the day and pick the initial consultation code based on that information.

Option 2: The ob-gyn provided consultative services and checked the monitoring frequently as a standard of good care. If you can make a case for prolonged services, you'll have to submit documentation indicating why she needed to be there for the total time she spent face-to-face with the patient.
 
"Face-to-face" patient care means that the ob-gyn must have personally interacted with the patient exclusively during the prolonged service time. But that doesn't mean the time must be continuous. You can still report prolonged services if the ob-gyn provides prolonged service during different time segments throughout the course of a day, coding experts say. That means leaving out the time she wasn't in the room. You'll only include the time she was active with the patient's care, without the fetal monitoring (because you'll report that with 59050).

Review Prolonged Services Ins and Outs

If your ob-gyn provides prolonged service in an inpatient setting, you should refer to two different prolonged service codes:
 

  • +99356 - Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond the usual service; first hour (list separately in addition to code for inpatient evaluation and management service) for the first hour
     
  • +99357 -  ... each additional 30 minutes (list separately in addition to code for prolonged physician service) for each additional half-hour.

    Remember: To use the first-hour prolonged service codes, you must provide at least 30 minutes of prolonged service time beyond the CPT-allotted time for that E/M service, coding experts say. In other words, you would not start counting until 30 minutes past the typical time attached to the consult or E/M code you billed.

    These codes are designed for physicians "who spend an inordinate amount of time, specifically 30 minutes, greater than the AMA's stipulated time limit for a given level of E/M service," says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

    And keep in mind that prolonged service codes are add-on codes, so they must be tagged to E/M services, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. Do  not report prolonged service codes alone, and never attach them to procedure codes.

    All payers do not accept prolonged service codes, so if you're not absolutely sure that your carrier accepts the codes, do not report them. In Falbo's area, "Medicare pays for them, but the other [payers] are case-by-case," she says.

    Good advice: Before reporting prolonged services, "query your top payer classes [on prolonged services] and obtain something in writing as an addendum to their managed-care contract," Falbo says.

    Make Your Stand: Not Transfer of Care

    You need to be sure that if you go with option number 2, then you make a strong case that the provider did not ask the ob-gyn to take over the patient's care.

    Remember, you can report a consult even if your physician schedules testing or initiates care for the patient - as long as the visit meets the requirements of request, render and report.

    CPT 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit." You should not code a new patient visit just because you see that a consulting physician has initiated services. In some circumstances, a consult includes rendered services and follow-up visits.

    Point to guidelines to support your claims: Many insurance companies that see a consult code alongside a treatment or procedure will automatically downcode the claim to a new patient visit. You should appeal as long as you have proof that there was no intent to transfer care on that visit, says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.

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