Ob-Gyn Coding Alert

One of the most frustrating aspects of obstetrical care is reimbursement for the global service. Rules and reimbursement rates vary among payers, especially when there are complications or other issues in the pregnancy that make it nonroutine. By defining in writing what your practice considers standard global ob care and getting payers to accept that definition, you can head off reimbursement problems.
 
An amendment to a payer contract defines the realm of global ob package and ensures maximum reimburse-ment. A typical amendment covers the services normally included in global care, the services not included as part of global care and how the pregnancy management is coded when a global code is not employed, e.g., antepartum visits, delivery charges (vaginal or C-section), postpartum care and complications.
 
Helene Stout, director of business services for Fort Collins Women's Clinic, a comprehensive women's health facility in Fort Collins, Colo., has developed an amend-ment that almost all of the practice's major payers have accepted as a part of their contracts with the clinic. "Our practices are driven by submitting the codes that best describe the services we have rendered and not to bundle and unbundle at will," Stout says. "Yet insurance com-panies seem not to be driven by those same rules and can adopt their own interpretations of coding rules." This was Stout's impetus for developing the amendment and fight-ing to have payers accept it.
Getting Payers To Play Ball  
Stout says that getting payers to agree to the practice's amendment "wasn't as hard as you may think." By using established criteria to develop her document, she had official "backup" if a payer challenged its contents. "The amendment closely follows CPT guidelines," Stout says, "so we are really not making up our own rules." Stout also consulted with ACOG for coding recommendations for multiple births. "Having these two organizations support the billing concept helps immensely." She feels that setting a very strict guideline for the payer is easier for them because it leaves very little to the discretion of the claims reviewer. All the parameters are easily programmed into the payers' computerized claims programs. "Most payers will sign the agreement," she says, "and for those with whom I have a history of difficulty, I simply mail a copy of the amendment with the claim."
 
Some payers still resist when asked to pay for E/M visits unrelated to the pregnancy, but documentation can solve that problem. "We require our doctors to dictate a complete E/M note when they provide and charge for this service," Stout says, "so that makes appealing a denial a little bit easier."
Pay Extra Attention to High Risk and Complications  
While Stout's amendment (see box on page 69) outlines the basics of uncomplicated [...]