Ob-Gyn Coding Alert

Learn how not to misuse the new 'pregnancy confirmed' code

Don't base your ob-gyn coding on myths and assumptions - if you do, you're asking for denials and lost reimbursement. Bust through the following four global ob myths and learn how to correctly report V72.42 when it becomes available Oct. 1.

Myth #1: You can initiate the ob record after both the nurse and ob-gyn see the patient.

Setup: Many coders believe that when your ob patients first meet with one of your nurses for the ordering of blood work, you should report a minimal visit (99201 or 99211). Then, when the patient is at 11 weeks, you set this patient up to meet with your ob-gyn for the first time to determine a viable pregnancy. For that service, they recommend you report 99203/99204 or 99214/99215 and include any visits thereafter as part of the global ob package.

The reality: If you're reporting your physician visits this way, you're incorrectly coding under everyone's rules. If you were to be audited, your payers would consider each and every one of these ob-gyn visits a part of the global, which means you can expect to give some refunds.

Let's say your nurse does a prenatal interview that lasts about an hour. She goes over risks, things to watch for, what is normal, and orders prenatal labs, urine cultures, and glucola.

In this case, you would report an established visit code (99211). The next visit with the ob-gyn (or nurse practitioner) would then begin the ob record, says Shari Kheul, CCS-P, coding and reimbursement specialist at Women's Health Services in Clinton, Iowa.

Note: In addition, if the nurse has already seen the patient, you cannot report the physician visit using a new patient code.

Rule of thumb: When you initiate the patient's antepartum record, then you'll always include that visit as part of the global service. You may be able to report the first visit when the ob-gyn or nurse performs a pregnancy test outside of the global, but you should consider all other visits related to pregnancy a part of the global package.

Myth #2: To be reimbursed for the initial ob workup, you should report 626.0.
 
Set up: When an ob-gyn sees an ob patient for the first time, some coders say that the only way to be paid for the first initial workup is to use 626.0 (Amenorrhea [primary] [secondary]). And only after that visit can you start the global ob package.

The reality: First, you should know that amenorrhea, by clinical definition, means no menstrual periods for six months or no periods for three months with documented irregular periods. You shouldn't use this code at a visit in which the ob-gyn diagnoses pregnancy. Otherwise, you'd be giving the patient a disease condition. 

Before Oct. 1, for the "absence of menstruation," you should report 626.8 (Missed period) instead. This will be your primary diagnosis code linked to the E/M code. You should also consider listing V22.0 (Supervision of normal first pregnancy) or V22.1 (Supervision of other normal pregnancy) as a supplementary diagnosis code for the urine test that confirmed the pregnancy. Remember: You must code what you know at the end of the visit.

Important: As of Oct. 1, you'll have the new ICD-9 code V72.42 (Pregnancy, confirmed). You will use this code when your ob-gyn simply tests to see whether the patient is pregnant, and the results are positive. You should link this diagnosis to both the E/M code and the urine test, because you'll be coding for what you know at the end of the visit. You won't need any other V codes.

Red flag: "Never code to get paid. You should code for the accuracy of the diagnosis at the time of the visit," says Jennifer Ohmart, medical billing, coding and insurance specialist at Anne Walters, CNM, Susan McConaughy, CNM, Amy Wallace, CNM, Wayne Furr, MD, Ob-Gyn, in Englewood, Colo.

In other words, don't revert to a diagnosis that you'll know will return reimbursement. That could set your practice up for charges of fraud and abuse.

Myth #3: Carriers will assume you began the ob record when you use V72.42.

Set up: Many coders believe that because carriers may use V72.42 to signify the start of the global ob package, you should continue reporting 626.8 and use V72.42 as the secondary code.

The reality: For a little while longer, you may continue to use the rules that mandate that you indicate a diagnosis of V22.0 (Supervision of normal first pregnancy)  or V22.1 (Supervision of other normal pregnancy) if you know she is pregnant at the end of the visit. Once Oct. 1 rolls around, you'll use V72.42 instead of these codes.

"Carriers should not recognize this code as the beginning of the global ob package, as long as your ob-gyn didn't initiate the ob record," King says.
 
Best bet: "Providers should be careful to document what is necessary to code the visit and not get into the history and physical. Those visits are separate, and the ob-gyn should perform them at a later date," King adds.

Myth #4: You have to include a threatened AB in the global care.

Set up: When a patient has problems due to a threatened AB, some coders think they cannot bill that visit outside of the global ob package.

The reality: The global ob package is designed to cover all prenatal care that is usual and customary. A threatened AB does not fit into the usual and customary. This is an urgent care issue for the evaluation and management of a difficulty in pregnancy.

Therefore, you should report this visit outside of the global service with the diagnosis of 640.03, Threatened abortion; antepartum condition or complication, or 640.83, Other specified hemorrhage in early pregnancy; antepartum condition or complication, Ohmart says.

Tip: The American College of Obstetricians and Gynecologists (ACOG) recommends that your encounter for a problem be documented outside your ACOG flow sheet. You should specifically mention "complication" in a separate area of the chart, says Michelle King, CPC, director of billing operations at the Baystate Ob/Gyn Group Inc. in Springfield, Mass.

"Many payers may deny these services or want them reported at the end of the pregnancy (such as, delivery or after). One way they may want you to report them is by itemization. They may also just want you to append a modifier 22 (Unusual procedural services), thus increasing the fee of the delivery," King adds. Query your payer to see which method they prefer.